COLUMBIA  LIBRARIES  Ohl-bMt 

HEALTH  SCIENCES  STANDARD 


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THE  LIBRARIES 


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HEALTH  SCIENCES 
LIBRARY 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseasOOfind 


A  TREATISE 


DISEASES  OF  WOMEN 


FOR  STUDENTS  AND  PEACTITIONERS 


BY 

PALMER  FINDLEY,  B.S.,  M.D. 

PROFESSOR    OF     GYNECOLOGY,     COLLEGE    OF'&IEDICINE,    STATE     UNIVERSITY     OF    NEBRASKA;    GYNECOLOGIST 

TO     THE     CLARKSON    MEMORIAL    HOSPITAL     AND     DOUGLAS     COUNTY    HOSPITAL;     FELLOW     OF    THE 

AMERICAN     GYNECOLOGICAL    SOCIETY;    FELLOW     OP    THE    AMERICAN    ASSOCIATION     OF 

OBSTETRICIANS    AND    GYNECOLOGISTS;    FELLOW     OP    THE    CHICAGO 

GYNECOLOGICAL    SOCIETY. 


ILLUSTRATED  WITH    632   ENGRAVINGS  IN  THE   TEXT  AND  38    PLATES 
IN   COLORS  AND  MONOCHROME 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 


//v3 


Entered  according  to  the  Act  of  Congress,  in  the  j^ear  1913,  by 

LEA  &  FEBIGER, 
in  the  office  of  the  Librarian  of  Congress.     All  rights  reserved. 


DEDICATED 

TO 

MY    FORMER    CHIEF 

J.    CLARENCE   WEBSTER 

WITH  ALL  RESPECT 


PREFACE 


This  book  is  the  natural  outgrowth  of  the  author's  Diagnosis  of 
Diseases  of  Women.  Much  that  was  contained  in  the  former  work 
has  been  revised,  the  subjects  have  been  reclassified,  and  more  than 
an  equal  amount  of  text  and  illustrations  has  been  added  for  the 
purpose  of  making  a  complete  text-book  on  the  subject  of  diseases  of 
women. 

It  has  been  the  endeavor  of  the  author  to  present  the  subject  in  detail 
without  encumbering  the  text  with  needless  repetitions.  With  this 
object  in  view,  separate  chapters  are  devoted  to  the  subjects  of  Non- 
operative  Methods  of  Treatment,  Hygiene  and  Dress,  Preparation 
of  Patient  for  Operation,  Preparation  of  Operating  Room,  Field  of 
Operation  and  Surgical  Utensils,  Choice  of  Anesthetics,  Diet,  Post- 
operative Complications  and  Care  of  Patients  after  Operation,  and 
frequent  references  are  made  to  these  subjects  throughout  the  text. 

An  effort  has  been  made  to  give  full  scope  to  the  discussion  of 
conservative  methods  of  treatment,  such  as  douches,  baths,  exercise, 
massage,  diet,  dress,  and  tampons.  The  author  is  of  the  opinion  that 
the  non-operative  methods  of  treatment  of  diseases  of  women  have 
not  received  their  due  share  of  consideration  in  text-books  and  in 
practice  which  they  rightly  deserve. 

The  subject  of  diagnosis  has  been  placed  on  an  anatomical  basis, 
both  macroscopic  and  microscopic,  for  it  is  preeminently  true  of  diseases 
of  women  that  the  making  of  a  diagnosis  is  in  large  part  the  recognition 
of  the  morbid  anatomy. 

There  are  certain  subjects  presented  in  the  text  which  may  be  con- 
sidered as  on  the  borderline  between  gynecology  and  obstetrics;  such 
are  surgical  treatment  of  puerperal  infection,  fibroids  of  the  uterus 
complicating  pregnancy,  prolapse  of  the  pregnant  uterus,  ovarian 
cysts  complicating  pregnancy,  and  the  immediate  repair  of  the  cervix 
and  pelvic  floor.  Such  subjects  emphasize  the  illogical  separation  of 
gynecology  and  obstetrics.  Because  of  their  relative  importance 
special  chapters  have  been  devoted  to  gonorrhea  and  tuberculosis  in 
women,  and  a  proportionately  large  amount  of  space  has  been  allotted 


VI  PREFACE 

to  the  discussion  of  fibroids  of  the  uterus,  cancer  of  the  uterus,  ovarian 
cysts,  extra-uterine  pregnancy,  pelvic  inflammations,  lacerations  of  the 
pelvic  floor,  and  retroversioflexion  and  prolapse  of  the  uterus. 

The  author  desires  to  express  his  indebtedness  to  Dr.  N.  Sproat 
Heaney  for  his  valuable  assistance  in  proof-reading;  for  the  service 
of  Mr.  Charles  F.  Bauer  in  preparing  the  illustrations,  and  for  the 
generous  and  courteous  cooperation  of  the  Publishers. 

P.  F. 

Omaha,  1913. 


COXTEXTS 


CHAPTER   I 


Introductory:     Hemorrhages  from  the  Genital  Tract 

The  Clinical  History 17 

Form  of  Case  Record 17 

Address 19 

Age 19 

Occupation 20 

Nationality 21 

Social  State 21 

Number  of  Children  and  Miscarriages 21 

General  Predisposing  Conditions 21 

Family  ffistory 21 

Previous  Illnesses 22 

Present  Complaints 22 

Menstrual  History 22 

Hemorrhage  from  the  Genital  Tract 22 

Hemorrhage  from  the  A'ulva 22 

Hemorrhage  from  the  Vagina 23 

Hemorrhage  from  the  Cervix 23 

Menstruation 23 

Anatomy  of  Menstruating  Uterus 24 

Tubal  Menstruation 26 

Menstruation  without  Ovaries 26 

Uterine  Hemorrhage 27 

Systemic  Causes 27 

Local  Causes ■ .  28 

Character  of  Dischai'ged  Blood 33 

Treatment  of  Uterine  Hemorrhage 33 

CHAPTER   II 

Disorders  Associated  with  ^Menstruation 

Amenorrhea 27 

General  Causes 37 

Local  Causes 39 

^Menstrual  Xlolimina ■    .      .      .  40 

Vicarious  Menstruation 40 

Diagnosis  of  Amenorrhea 40 ' 

Treatment  of  Amenorrhea : 41 

Dysmenorrhea 42 

Primary,  Causes  of 42 

Secondary,  Causes  of 43 

Membranous  Dysmenorrhea 45 

Intermenstrual  Pain 47 

Treatment  of  Dysmenorrhea 48 

Backache 56 

Causes 56 

Static  Backache  and  Treatment 57 

Gonorrheal  Arthritis 58 

Treatment 58 

CoccygodjTiia 58 

Diastasis  Recti:     Enteroptosis 59 

Causes 60 

SjTnptoms 60 

Treatment 61 


viii  CONTENTS 


CHAPTER   III 

Leucorrhea — Sterility — The  Menopause 

Leucorrhea: 

Normal  Secretions  of  the  Genital  Organs 63 

Clinical  Grouping  According  to  Age — 

Infants 63 

Virgins 64 

Sexual  Matm-ity 64 

Old  Age    ... ,  •      •      •  64 

Odor  as  an  Aid  to  Diagnosis 65 

Treatment ^ 65 

Sterility: 

Definitions 67 

One-child  SteriHty 67 

Conditions  Essential  to  Conception 67 

Etiology 68 

General  Causes 68 

Local  Causes 69 

Treatment 72 

The  Menopause: 

Premature  Menopause 73 

Delayed  Menopause 74 

Time  of  Appearance 74 

Clinical  Manifestations 75 

Influence  of  Morbid  Conditions  in  the  Pelvis 76 

Management  of  the  Menopause 76 

CHAPTER  IV 

Examinations  of  the  Blood — Bacteriological  Examinations 

Examinations  op  the  Blood 78 

Morphology  of  Blood  Cells 78 

Red  Cells 78 

White  CeUs 79 

Leucocytosis  of  Pregnancy 80 

Postpartum  Leucocytosis 80 

Posthemorrhagic  Leucocytosis 80 

Inflammatory  Leucocjiiosis 81 

Leucocytosis  of  Mahgnancy 82 

Leucocytosis  of  Ovarian  Tumors 82 

Differential  Count  of  Leucocytes .  82 

Secondary  Anemia 83 

Bacteriological  Examinations  : 

Bacteriology  of  Normal  Genital  Tract 84 

Bacteriology  of  Vulva  and  Vagina 85 

Bacteriology  of  Uterus 86 

Bacteriology  of  Fallopian  Tubes 87 

Bacteriology  of  Ovary 88 

Bacteriology  of  Peritoneum  and  Pelvic  Cellular  Tissue 89 

CHAPTER  V 
General  Physical  Examination 

Preliminary  Measures ' .      .  90 

External  Abdominal  Examination  ." .  91 

Inspection 91 

Palpation 93 

Percussion 97 

Auscultation 99 

Mensuration 99 


CONTENTS  ix 

CHAPTER  VI 

Examination  of  External  and  Internal  Genitalia 

Inspection  of  External  Genitalia 100 

Digital  Examination  of  Internal  Genitalia 100 

Digital  Examination  of  Vagina 100 

Combined  Vaginal  Examination      . 106 

Abdominovaginal  Examination 107 

Palpation  of  Ureters  thi'ough  the  Vagina 112 

Digital  Examination  of  the  Rectum 112 

Pelvimetry : 117 

CHAPTER  VII 

Instrumental  Examination 

Vaginal  Speculum 118 

Vulsellum  Forceps 120 

Uterine  Dilators 121 

Uterine  Sound 122 

Preliminary  Procedures 123 

Indications 123 

Contra-indications 125 

Dangers 125 

Uterin'e  Curet 126 

Indications 126 

Contra-indications 127 

Dangers 128 

Technic 129 

In  Treatment 130 

Exploratory  Punctures  and  Incisions       .      .    • 132 


CHAPTER  VIII 

Microscopic  Examination  op  Scrapings  and  Excised  Parts — The  Diagnosis 
OF  Expelled  Membranes  from  the  Uterus 

Removal  op  Uterine  Tissue  for  Diagnostic  Purposes 133 

Test  Excision  from  the  Cervix 134 

Test  Curettage  of  the  Uterus 134 

Frozen  Sections  op  Excised  Pieces  and  Scrapings 134 

Fixing  the  Specimens 136 

Hardening  and  Embedding 136 

Staining  and  Mounting .  138 

Inspection  of  Uterus  after  Removal 139 

The  Diagnosis  of  Expelled  Membranes  from  the  Uterus    ....  140 

Membranous  Dysmenorrhea 140 


CHAPTER  IX 

Ectopic  or  Extra-uterine  Pregnancy 

Etiology 143 

Recurrent  and  Multiple  Ectopic  Pregnancy 144 

Combined  Uterine  and  Tubal 145 

Bilateral  Tubal 145 


X  CONTENTS 

Classification 146 

Ampullar 147 

Interstitial 150 

Infundibular 150 

Ovarian 151 

Causes  of  Ending  of  Gestation 152 

Retrogressive  Changes  in  Dead  Fetus 154 

Anatomic.u.  Changes  in  Tube 154 

Clinic-Uj  Diagnosis 155 

Subjective  Signs 156 

Objective  Signs 156 

Differential  Diagnosis 158 

Treatment 164 

Uni-uptured  Tubal  Pregnancy 164 

At  Time  of  Rupture 165 

Late  after  Rupture 167 

Intraligamentary  Extra-uterine  Pregnancy 170 

Interstitial  Pregnancy 170 

Advanced  Extra-uterine  Pregnancy 170 

Combined  Extra-uterine  and  Intra-uterine 171 

Ovarian  Pregnancy 171 

Pregnancy  in  Rudimentary  Horn  of  Uterus 171 

MoRT-iLiTY  OP  Extra-uterine  Pregnancy 172 


CHAPTER  X 
Chorioepithelioma  Malignum 

Etiology 174 

Clinical  Diagnosis 175 

Macroscopic  Appearance 176 

Microscopic  Appearance 176 

Malignant  Degeneration  of  Hydatiform  Mole 177 

Primary  Chorioepithelioma  Outside  of  the  Placental  Site       .      .      .  182 

Histogenesis 184 

Diagnosis 185 

Treatment 186 


CHAPTER  XI 

Non-operative  Methods  of  Treatment 

Hydrotherapy      188 

Baths 189 

Vaginal  Douche 196 

Intra-uterine  Douche 200 

Saline  Injections 202 

Enteroclysis 203 

Hypodermoclysis 204 

Intravenous  Injections 205 

Ice  Bag 207 

Hot  Compresses 207 

Hot-water  Bag 207 

Water  Drinking '  .  208 

Hot  Air  Treatment .  209 

Hot  Pack 210 

Counterirritation 211 

Tampons 211 

Pelvic  Massage 215 

Pressure  Therapy 220 

Electricity 223 


CONTENTS  xi 

X-KAY  Therapy 223 

Swabs 225 

Serum  and  Organotherapy      . 227 


CHAPTER  XII 

Hygiene  and  Dress 

Hygiene  op  the  School-girl 229 

Physical  Training  in  Schools 230 

Public  Playgrounds  and  Baths 230 

Indoor  Exercise 230 

Dress 237 

Corsets ■    .      .  239 


CHAPTER  XIII 

Preparation  of  Patient  for  Operation 

Examination  for  Contra-indications 242 

Local  Treatments  Preparatory  to  Operation 243 

Preparation  of  the  Field  of  Operation 244 

Choice  of  Local  or  General  Anesthesia 246 

Local  Anesthesia 247 

General  Anesthesia 248 

Spinal  Anesthesia 250 

Combined  Gynecological  Operations 250 

Diet 251 


CHAPTER  XIV 

Principles  of  Asepsis  in  Gynecology 

Sterilization  op  Field  of  Operation 252 

Disinfection  of  Hands  and  Forearms 252 

Preparation  of  Surgical  Utensils  . 254 

Preparation  of  Gauze  and  Sutures 255 

Preparation  of  Instruments 256 

Sterilized  Water 257 

Preparation  of  Operating  Room 257 

Preparation  for  Operation  in  Private  House 258 

Operating  Bag 260 


CHAPTER  XV 
Anomalies  and  Malformations  of  the  Genital  Organs 

Anomalies  and  Malformations  op  the  Vulva 262 

Absence  of  Vulva 262 

Double  Vulva 262 

Atresia  of  Vulva 262 

Infantile  Vulva 263 

Hypertrophy  of  Vulva 264 

Congenital  AnomaKes  of  Clitoris     . 264 

Adhesions  of  the  Prepuce 265 

Congenital  Fissures  of  the  Vulva 265 

Anatomy  and  Malformations  op  the  Hymen 267 

Cysts  of  the  Hymen .269 


xii  CONTENTS 

Anomalies  and  Malformations  of  the  Vagina 270 

Absence 270 

Atresia  and  Stenosis 272 

Double  Vagina 275 

Blind  Pouches 276 

Anomalies  and  Malformations  of  the  Uterus 276 

Uterus  Deficiens 276 

Uterus  Rudimentarius 279 

Uterus  Foetalis 279 

Uterus  Unicornis 280 

Uterus  Septus 282 

Uterus  Bicornis 282 

Uterus  Didelphys 286 

Uterus  Accessorius 286 

Anomalies  and  Malformations  of  the  Fallopian  Tubes 286 

Anom.alies  and  Malformations  op  the  Ovaries 286 

Absence  of  One  or  Both  Ovaries 286 

Congenital  Smallness  of  One  or  Both  Ovaries 287 

Supernumerarj'  Ovaries 287 

Congenital  Largeness  of  One  or  Both  Ovaries 287 


CHAPTER  XVI 

Malpositions  of  the  Genital  Organs 

Malpositions  of  the  Vagin.al  Walls 288 

Cystocele 288 

Rectocele 299 

Vaginal  Hernia  302 

Malposition  of  the  Uterus 305 

Normal  Position "...  305 

Pathological  Mobility 308 

Pathological  Fixation 308 

Anteposition 309 

Retroposition 310 

Lateroposition 312 

Elevatio  Uteri 313 

Torsion       . '. 315 

Prolapsus  Uteri 315 

Prolapse  of  the  Pregnant  Uterus 333 

Inversion 334 

Anteversion 345 

Anteflexion 347 

Retroversioflexion 352 

Hernia 381 

Malpositions  of  the  Fallopian  Tubes 382 

Normal  Position 382 

Changes  in  Position 384 

Malpositions  of  the  Ov.\ries 384 

Normal  Position  and  Histology 384 

Changes  in  Position 386 

Descensus  Ovarii 386 

Hernia  of  Tube  and  Ovary  .      .      : 388 


CHAPTER  XVII 

Circulatory  Disturbances  and  Inflammations  of  the  Genital  Organs 

Bacteriology  of  the  Normal  Genital  Tract 389 

Etiology 390 

General  Causes 390 

Local  Causes 391 


CONTENTS  xiii 

CHAPTER  XVIII 

Circulatory  Disturbances  and  Inflammations  of  the  Vulva  and  Vagina 

Circulatory  Disturbances  of  the  Vulva 393 

Varicose  Veins  (Angioma  Vulvae) 393 

Hematoma  of  the  Vulva 395 

Edema  of  the  Vulva 396 

Gangrene  of  the  Vulva .  396 

Noma  Pudendi 397 

Inflammation  of  the  Vulva 397 

Vulvitis 397 

Simple  Catarrhal 397 

Gonorrheal 398 

Erysipelatous 398 

Puerperal 399 

Tuberculous 399 

SyphiUtic 399 

Diphtheritic 399 

Actinomycosis 400 

Treatment 404 

Barthohnitis 401 

Vulvitis  Furimculosis 401 

Pruritus  Vulvae 403 

Inflammation  of  the  Vagina 406 

Vaginitis  (Colpitis) 406 

Catarrhal 407 

Ulcerative 407 

Tuberculous 408 

Emphysema  Vaginae 408 

Condylomatous 419 

Senile. 409 

Paravaginitis 411 

Vaginismus 412 


CHAPTER  XIX 

Inflammations  op  the  Uterus 

Endocervicitis  (Endometritis  Cervicalis) 415 

Erosions  of  the  Cervix 416 

Simple 417 

Papillary .      .  • 417 

FolUcular 417 

Ulcers  of  the  Cervix 420 

Decubitus 420 

Tuberculous 420 

Cancerous 420 

Tuberculosis  of  the  Cervix 420 

Endometritis 420 

CUnical  Classification 421 

Acute 421 

Chronic    . 422 

Hemorrhagic 4---^ 

Catarrhal 422 

Dysmenorrheic '±^^ 

Tuberculous 423 

Gonorrheal 4-3 

Decidual 42^ 

Puerperal ■      •      •      •  424 

Postabortive 424 

ExfoMative 424 

Semie 425 


xiv  CONTENTS 

EXDOMETRITIS: 

Anatomical  Classification 425 

Macroscopic 426 

Hj-pertrophic 426 

Fungous 426 

Villous 426 

Pohpoid 426 

ricerative    . 426 

Pseudodiphtheritic 426 

Microscopic 427 

Glandular 427 

Interstitial 431 

Chroxic  Metritis 438 

Abscess  of  the  Uterus 438 

Treatment  of  Inflammation  of  the  Uterus  . 434 

Acute  Metritis 434 

Chronic  Metritis 438 

Endocer\'icitis 442 

Erosions  of  the  Cer\'ix 444 

CILIPTER   XX 

Circulatory  Disturb.^nces,  Intl-^j^imations,  and  Infectious  Grantjlomata  of 
Fallopi.^n  Tubes  and  Ov.vries 

Circulatory  Disturb.\nces  in  the  F.u.lopian  Tube 445 

Causes 445 

Anatomical  Diagnosis 446 

Clinical  Diagnosis 446 

Inflammations  .\nd  Infectious  Gr.vnulomata  of  the  Fallopi.\n  Tube       .  446 

General  Considerations 446 

Classification  of  Salpingitis 447 

Catarrhal 447 

Purulent 452 

Tuberculous 462 

Sj-phihs  of  the  Fallopian  Tube 466 

Actinomj-cosis  of  the  Fallopian  Tube 466 

Parasites  of  the  Fallopian  Tube 462 

Treatment  of  Inflammatorj'  Diseases  of  the  Tubes 467 

Xon-operative  Treatment 467 

Conservative  Operations 468 

Radical  Surgical  Treatment 470 

Operative  Treatment 471 

Circulatory  Disturbanxes  in  the  Ov.\ry 480 

Etiolog}' 480 

Anatomical  Diagnosis 480 

Clinical  Diagnosis 482 

Intlammations  of  the  Ovary  (Oophoritis,  Ovaritis) 483 

Acute  Ovaritis 483 

Chronic  Ovaritis 483 

Cj'stic  Degeneration  of  the  Ovaries 484 

Abscess  of  the  Ovary 489 

CHAPTER  XXI 

Peritonitis 

Gen'er.a^l  Peritonitis '  .  493 

Xon-septic,  Traumatic 493 

Septic 494 

Postoperative 495 

Puerperal 500 

Gonorrheal 501 

Tuberculous 502 

Pel-vtc  Peritonitis 503 


CONTENTS                                    '  XV 

CHAPTER  XXII 

Parametritis  (Pelvic  Cellulitis) 

Acute  Parametritis 510 

Chronic  Parametritis 512 

Varicocele  of  the  Broad  Ligament 517 

CHAPTER  XXIII 

Gonorrhea  in  Women 

Historical  Sketch 519 

GoNOcoccus  OF  Neisser 519 

Etiology 519 

Diagnosis 522 

Prognosis 527 

Prophylaxis 529 

Treatment 529 

Gonorrhea  in  Children 536 

CHAPTER  XXIV 

Tuberculosis  of  the  Genital  Organs 

Etiology 539 

1.  Primary  Infection 540 

2.  Secondary  Infection 540 

Tuberculosis  of  the  Vulva  and  Vagina 540 

Tuberculosis  of  the  Cervix .  541 

Tuberculosis  of  the  Uterus 541 

Tuberculosis  of  the  Ovaries 541 

Tuberculosis  of  the  Fallopian  Tubes 541 

Tuberculous  Peritonitis 544 

Prognosis 544 

Treatment 545 


CHAPTER  XXV 

Nutritional  Disturbances  of*  the  Genital  Organs 

Retrogressive  Tissue  Changes 546 

Atrophy  of  the  Vulva  (Kraurosis  Vulvae) 546 

Atrophy  of  the  Vagina 549 

Atrophy  of  the  Uterus     .      .      .     , 549 

Physiological  Atrophy 549 

Superinvolution  of  the  Uterus 549 

Atrophy  of  the  Ovary 550 

Progressive  Tissue  Changes 551 

Elephantiasis  Vulvae 551 

Condyloma  Acuminata 552 

Hypertrophy  of  the  Vulva 553 

Hypertrophy  of  the  Clitoris 553 

Hypertrophy  of  the  Labia 553 

Hypertrophy  of  the  Cervix 553 

Supravaginal  Hypertrophy 554 

Infra  vaginal  Hypertrophy 554 

Subinvolution  of  the  Uterus ^^^ 

Hypertrophy  of  the  Ovary ^^° 


xvi  CONTENTS 


CHAPTER  XXVI 

New  Formations  of  the  Vulva  and  Vagina 

New  Formations  of  the  Vulva 559 

Benign  Tumors  of  the  Vulva 559 

Fibroma 559 

Lipoma 559 

Enchondroma 559 

Neui-oma 559 

Sebaceous  Cysts 559 

Dermoid  Cysts 560 

Vulvar  Cysts 560 

Cysts  of  the  Hjanon 560 

Cancer  of  the  Vulva 562 

Sarcoma  of  the  Vulva .  567 

New  Formations  of  the  Vagina .  567 

Cysts  of  the  Vagina 567 

Fibromyoma  of  the  Vagina 569 

Carcinoma  of  the  Vagina 570 

Sarcoma  of  the  Vagina  574 

Syncytioma  Vaginae 574 

Endothelioma  of  the  Vagina 574 


CHAPTER  XXVII 

Fibromyoma  of  the  Uterus 

Etiology 575 

Histogenesis 576 

Anatomical  Diagnosis 577 

Recurrence 584 

Microscopic  Diagnosis 584 

Adenofibromyoma  Uteri 585 

Degenerations  of  Fibroids 586 

Clinical  Characteristics 591 

Clinical  Diagnosis 592 

Differential  Diagnosis 597 

Effect  on  Neighboring  Organs 604 

Treatment 605 

Operations  for  Uterine  Fibroids 608 

Vaginal  Myomectomy 609 

Vaginal  Hysterotomy 612 

Vaginal  Celiotomy 614 

Abdominal  Myomectomy 617 

Hysteromyomectomy 620 

Vaginal 620 

Abdominal 621 

Fibroids  Complicating  Pregnancy,  Labor,  and  Puerperium   ....  630 


CHAPTER  XXVIII 

Carcinoma  and  Sarcoma  of  the  Uterus 

Carcinoma  of  the  Uterus .  632 

Topographical  Classification 632 

Etiology • 632 

Anatomical  Diagnosis 634 

Clinical  Diagnosis 639 

Differential  Diagnosis 644 

Diagnosis  of  Extension 651 


CONTENTS  xvii 

Carcinoma  op  the  Uterus: 

Treatment 658 

Operative  Treatment 660 

Simple  Vaginal  Hysterectomy 660 

Byrne  Method 660 

Schuchardt  Operation 662 

Radical  Abdominal  Operation 665 

Treatment  of  Cancer  of  Cervix  Complicating  Pregnancy 676 

Treatment  of  Inoperable  Cancer  of  Cervix 677 

Treatment  of  Cancer  of  Body  of  Uterus 679 

EndotheKoma 692 

Sarcoma  op  the  Uterus 693 

Etiology 693 

Anatomical  Diagnosis 694 

Microscopic  Diagnosis  , 696 

Clinical  Diagnosis 697 

Prognosis * 697 

Treatment 698 

CHAPTER  XXIX 

Tumors  op  the  Pelvic  Ligaments,  Fallopian  Tubes,  and  Vagina 

Tumors  op  the  Pelvic  Ligaments 699 

Tumors  of  the  Broad  Ligaments 699 

Tumors  of  the  Ovarian  Ligaments 699 

Tumors  of  the  Roimd  Ligaments ...  700 

Treatment 700 

Tumors  op  the  Fallopian  Tubes ...  700 

PapiUoma 700 

Polyps 701 

Myoma  and  Fibroma 701 

Dermoid  Cysts 701 

Lipoma 701 

Fibromyxoma  Cystoma  of  the  Fimbriae 701 

Sarcoma , 701 

Carcinoma 701 

Cystic  New  Formations  of  the  Fallopian  Tubes 703 

Hydatids  of  Morgagni 703 

New  Formations  op  the  Ovary 703 

Simple  Cysts 703 

Folhcular  Cysts 703 

Corpus  Luteum  Cysts 703 

Tuboovarian  Cysts 703 

Tumors  of  the  Ovaries 706 

Carcinoma 712 

Dermoid  Cysts 714 

Connective-tissue  New  Formations 715 

Fibroma •  715 

Myoma 715 

Myxoma .      .      .  715 

Enchondroma  and  Osteoma 715 

Angioma  and  Lymphangioma 715 

Sarcoma 715 

EndotheHoma 717 

Parovarian  Cysts 718 

Ovariotomy 736 

Vaginal 737 

Abdominal 739 

Malignancy  of  Ovarian  Tumors 742 

Treatment  of  Ovarian  Tumors  Complicating  Pregnancy,  Labor,  and  the 

Puerperium 744 

Postoperative  CompUcations •      •  744 

Mortality. 752 

Conservative  Operations 753 


xviii  CONTENTS 

CHAPTER  XXX 

Trattmatic  Injuries  of  the  Genital  Organs 

Wounds  of  the  Vulva  and  Pelvic  Floor 762 

Colpoperineorrhaphy 763 

External  Superficial  Tear 763 

Internal  Tear  and  Combined  External  and  Internal  Tears  (Incomplete 

Laceration  of  the  Perineum) .  765 

Late  Repair  of  a  Complete  Rupture  of  the  Rectovaginal  Septum     .      .      .  782 

Repair  of  the  Sphincter  Ani  Muscles 786 

Relaxed  Outlet  of  the  Rectovaginal  Septum 786 

After-treatment  of  Plastic  Operations  on  the  Pelvic  Floor  .      .      .  788 

Wounds  of  the  Vagina 788 

Acquired  Stenosis  and  Atresia  of  the  Vagina 790 

Wounds  of  the  Cervix 791 

Immediate  Repair  of  a  Lacerated  Cervix 793 

Amputation  of  the  Cervix 795 

Perforating  Wounds  of  the  Uterus 797 


CHAPTER  XXXI 

Fecal  and  Genito-urinary  Fistula 

Fecal  Fistula 801 

Rectovaginal  Fistula 801 

Retroperineal  Fistula 804 

Rectolabial  Fistula 805 

Enterovaginal  Fistula 806 

Genito-urinary  Fistula 806 

Urethral  Fistula 806 

Vesical  Fistula 807 

Vesicovaginal  Fistula 807 

Vesico-uterine  Fistula 810 

Vesicocervical  Fistula 810 

Enterovesical  Fistula 811 

Ureteral  Fistulae 821 

Ureteral  Fistula  at  Vault  of  Vagina 821 

Ureterocystostomy 822 

Nephro-ureterectomy 823 


CHAPTER  XXXII 

Diseases  of  the  Urinary  System 

Diseases  of  the  Urethra  and  Bladder 824 

Anatomy  and  Physiology            825 

Methods  of  Examination 829 

Percussion .■ 829 

Palpation 829 

Catheter  and  Sound 830 

Inspection 830 

Urethroscopy '  .  830 

Cystoscopy .  830 

Malformations  and  Diseases  of  the  Urethra 845 

Congenital  MaKormations 845 

Partial  or  Complete  Absence 845 

Atresia 845 

Displacement 846 


CONTENTS  xix 

Malformations  and  Diseases  op  the  Urethra: 

Epispadias 846 

Hypospadias 846 

Acquired  Malformations 846 

Dilatation 846 

Strictiire 847 

Dislocations 848 

Prolapse  of  the  Urethral  Mucous  Membrane 848 

Urethritis 848 

Acute 849 

Chronic 849 

Newgrowths  of  Urethra 850 

Caruncle '     .      .      .      .  851 

Fibroma 851 

Carcinoma 851 

Sarcoma 851 

Foreign  Bodies 851 

Diseases  of  the  Bladder 852 

Developmental  Deformities 852 

Vesical  Fissure 852 

Double  Bladder "     .  853 

Loculate  Bladder 853 

Malpositions  and  Malformations 853 

Eversion 855 

Hernia 855 

Foreign  Bodies 855 

Cystitis 857 

Hyperemia 864 

New  Formations 864 

Myoma 864 

Fibroma 865 

Papilloma 865 

Adenoma 865 

Dermoid  Cysts 866 

Carcinoma •  866 

Sarcoma 866 

Diseases  of  the  Ureters 869 

Anatomy  and  Physiology 869 

Methods  of  Examination 870 

Palpation 870 

Inspection 870 

Catheterization 870 

Examination  of  Urine 873 

Congenital  Anomalies 874 

Inflammations  of  the  Ureter 876 

Obstructions  of  the  Ureter 878 

Ureteral  Calculus 881 

Stricture •  883 


CHAPTER  XXXIII 

Post-operative  Treatment 

Responsibility  for  Complications 886 

Stimulation 888 

Position  of  Patient 889 

Rehef  from  Pain 890 

Nourishment •      •  891 

Evacuation  of  Bladder 891 

Care  of  the  Bowels 893 

Apphcation  of  Ice  to  Abdomen 893 

Duration  of  Convalescence 894 

Early  Rising •      •  cor 

Abdominal  Supporters •  °y" 


XX  CONTENTS 

CHAPTER  XXXrV 

Complications  Following  Operations 

Surgical  Shock 897 

Pulmonary  Embolism ^y^ 

Ileus 903 

Pneumonia  ^J^o 

Acute  Bronchitis ■      ■      ■ 

PosTOPERATm;  Pleurisy •      •           •  907 

Gangrene  of  the  Lungs 908 

Abscess  of  the  Lungs 908 

Pulmonary  Edema 908 

Local  and  General  Infections 908 

Peritonitis 909 

Fermentation  Fever  ...                  909 

Septic  Litoxication 910 

Septicemia 910 

Pyemia       .... 911 

Breaking  of  Stitches 911 

PosTOPERATI^^E  Hernia .  913 

PoSTOPER.iTIA'E    HeM.\TEMESIS 916 

Retention  ant)  Suppression  of  L'rixe 917 

POSTOPER.^TIVE   NeUKOSES 917 

Hysteria 917 

Neurasthenia  . 917 

Insanity 917 

Tymp-\nites 918 

Phlebitis 920 

Acute  Dilatation  of  the  Stomach 921 

Vomiting 921 

Postoperative  Cystitis 922 

Acute  Nephritis 924 

Traumatic  Fistul-e  ....           924 

Ureteral  Fistulse   .      .  ' 925 

Vesical  Fistulse 925 

Rectal  Fistulse 925 

Pressure  Paralysis 925 

Burns 925 

Emphysema  of  the  Abdomin.\l  Walls 925 

Poisoning  by  Drugs 925 

Intectious  and  Contagious  Diseases 926 

Diarrhea 926 

Bed-sores 926 

Acid  Intoxication     .      .* 926 

Ophthalmia 927 

Late  Chloroform  .\nd  Ether  Poisoning 927 

Irregul.\rities  of  the  Pulse .  927 

Excessht:  Pain .     .  927 

Variations  in  Body  Temperature 928 

Second.\ry  Hemorrhage '  .      .      .  928 

Foreign  Bodies  Left  in  the  Abdominal  CA\^TY  after  Operation   .      .  930 


DISEASES  OF  WOMEN 


CHAPTER  I 


THE  CLINICAL  HISTORY— HEMORRHAGE  FROM  THE 
GENITAL  TRACT 

Clinical  History 
Form  of  Case  Record 

The  Clinical  History. — ^In  the  making  of  a  diagnosis  the  first  impor- 
tant step  is  the  recording  of  a  clinical  history.  A  carefully  recorded 
history  has  many  advantages;  it  serves  as  a  guide  to  a  systematic 
examination,  and  places  before  the  physician  a  detailed,  logical  record 
of  the  case  for  future  reference. 

It  is  manifestly  impossible  always  to  follow  a  set  form  in  case-taking, 
neither  is  it  possible  always  to  adhere  to  the  very  good  general  rule 
of  taking  the  full  history  at  the  time  of  the  first  examination. 

The  nervous  state  of  the  patient,  together  with  many  other  factors, 
may  preclude  the  taking  of  a  complete  history  at  the  time  of  the  first 
consultation,  but  on  each  occasion  certain  definite  items  may  be  recorded, 
and  the  history  completed  at  a  subsequent  visit. 

It  is  well  to  begin  with  permitting  the  patient  to  recite  her  complaints 
without  interruption.  The  patient  becomes  self-possessed,  while  at  the 
same  time  the  physician  is  given  an  opportunity  to  observe  her  general 
appearance,  temperament,  complexion,  nutrition,  carriage,  and  many 
other  points  bearing  upon  her  case.  After  a  time  direct  questions 
may  be  put  to  her,  and  as  the  answers  are  given  they  may  be  concisely 
placed  on  record. 

Form  of  Case  Record. — In  all  text-books  students  are  given  a  blank 
form  to  be  filled  out  in  the  taking  of  a  history.  Such  forms  are  of 
great  service  to  the  inexperienced  practitioner,  but  for  one  who  through 
long  experience  has  acc^uired  the  art  of  case-taking  they  are  unneces- 
sary and  ill-adapted.  The  allotted  space  may  be  inadequate  to  suit  indi- 
vidual requirements.  The  card-index  system  is  gaining  favor  and  is 
highly  commendable.  The  author  prefers  his  letter-head,  upon  which 
the  answers  to  questions  can  be  hurriedly  jotted,  and  to  which  subse- 
quent notations  can  be  added.     This  is  placed  in  an  envelope,  on  which 


18  THE  CLINICAL  HISTORY 

is  recorded  the  name  and  address.  These  envelopes  can  be  filed  away  in 
alphabetical  order.  Notes  from  all  subsequent  examinations,  copies  of 
prescriptions,  correspondence  with  patient  and  physician,  can  all  be 
placed  in  the  envelope  from  time  to  time.  When  visiting  the  patient 
the  envelope  can  be  placed  in  the  pocket  and  referred  to  on  the  way. 
As  a  compromise  between  the  elaborate  printed  forms  and  the  blank 
letter-head,  the  following  form  is  recommended  for  simplicity,  accuracy, 
and  liberal  spacing: 


Name 

Address 

Date 

Patient  of  Dr. 

Address 

Age 

Occupation 

■  Nationality 

S.  M.  W. 

Para 

Miscarriages 

Personal  habits. 

Events  following  childbirths  and  miscarriages. 

Family  historj-. 

Previous  illnesses. 

Present  complaints. 

Menstrual  history. 

Uterine  hemorrhage. 

Menstrual  pain. 

Intermenstrual  pain. 

Leucorrhea. 

General  physical  findings. 

Urinary  sj^stem. 


IMenses  began 

Type 

Quantity 

Duration 

Pain 

^lenopause 

Urinalysis : 

Amount  in  twenty-four  hours 

Color 

Reaction 

Albumin 

Total  soUds 

Urea 

Sp.  gr. 
Sugar 
Microscopic 


Physical  findings  in  pelvis  and  abdomen : 
Abdominal  wall 

Tender  on  pressure  ,    Swellings 

Visceroptosis 

Pelvic  floor. 

Vagina. 

Cervix. 

Uterine  body. 

Tubes 


FORM  OF  CASE  RECORD  19 

Ovaries. 

Urethra. 

Bladder. 

Rectum. 

Appendix. 

Extragenital  structures. 

Diagnosis. 

Treatment. 

Termination. 

A  discussion  of  the  different  items  will  be  of  practical  interest. 

Address. — The  place  of  residence  is  inquired  into,  not  only  as  a 
matter  of  business,  but  also  to  determine  the  possible  influence  of 
the  environment  upon  the  general  health  of  the  individual.  ^Malarial 
districts,  congested  portions  of  the  city,  extremely  warm  or  cold 
climates  and  high  altitudes  exercise  a  definite  influence  upon  the 
general  and  local  condition  of  a  woman. 

Without  a  favorable  environment  it  is  difficult  to  get  desired  results 
in  the  treatment  of  many  of  the  diseases  affecting  women.  The  local 
conditions  may  be  corrected,  but  if  the  place  of  residence  and  occupa- 
tion are  not  favorable  to  the  general  well-being  the  results  will  be 
disappointing.  This  is  clearly  demonstrated  in  the  speedy  convales- 
cence of  patients  who  pass  their  convalescing  days  far  removed  from 
home  and  hospital  where  they  find  rest,  healthful  exercises,  and  new 
associations. 

Age. — The  special  disturbances  found  in  the  various  stages  of  life — 
i.  e.,  infancy,  puberty,  sexual  maturity,  climacteric  and  postclimacteric 
— are  at  once  suggested  when  the  age  of  the  patient  is  known. 

In  infancy,  malformations  and  inflammations  of  the  lower  genital 
tract  are  to  be  looked  for;  tumors,  displacements,  and  traumatisms 
seldom  appear.  Infections  rarely  extend  beyond  the  vagina.  ^lore 
often  they  are  limited  to  the  vulva  by  the  hymen,  which  serves  as  a 
barrier. 

At  puberty,  malformations  of  the  genital  organs  are  commonly 
first  noticed  through  failure  of  the  menses  to  appear;  congenital  dis- 
placements first  cause  disturbance  at  this  time,  because  of  the  increase 
in  the  size  of  the  uterus  and  the  establishment  of  menstruation; 
infiammations  are  usually  confined  to  the  vulva,  rarely  extending 
above  the  hymen,  while  new-formations  and  traumatisms  are  seldom 
observed. 

During  the  period  of  sexual  maturity  all  lesions  of  the  genital  organs 
may  be  found.  Congenital  malformations  may  first  be  observed  after 
marriage  and  in  childbearing.  Inflammatory  lesions,  involving  part 
or  all  of  the  genital  tract,  most  often  arise  as  the  resiflt  of  chfldbearing, 


20  THE  CLINICAL  HISTORY 

specific  infection,  and  instrumental  and  digital  manipulations.  New- 
formations  usually  make  their  appearance  in  this  period.  Displace- 
ments and  traumatisms  occur  as  the  result  of  childbearing  and  rarely 
arise  at  any  other  time  of  life. 

In  the  climacteric  and  postclimacteric  periods  all  disorders  have 
a  special  clinical  significance.  The  possibility  of  malignancy  should 
always  be  borne  in  mind.  After  seventy  it  is  unusual  for  any  lesion 
to  develop.  No  disorder  should  be  regarded  lightly  when  arising  at 
the  end  of  the  childbearing  period.  The  onset  of  malignant  disease  is 
so  insidious  and  so  misleading  in  its  clinical  manifestations  that  no 
physician  can  afford  to  look  lightly  upon  any  disorder,  however  trivial 
it  may  seem  to  the  patient  and  ph^'sician. 

Occupation. — Occupation  is  an  important  factor  in  the  causation 
and  aggravation  of  pelvic  disorders.  In  young  girls  confined  to  w^ork- 
shops  the  menstrual  functions  are  seldom  perfectly  established.  Poor 
ventilation,  long  working  hours,  heavy  lifting,  and  poor  food  exercise 
an  unfavorable  influence  upon  the  development  of  the  pelvic  viscera 
and  tend  to  aggravate  existing  maladies.  On  the  other  hand,  sedentary 
and  indolent  habits  are  equally  injurious. 

While  it  is  true  that  occupation  is  essential  to  health,  it  is  also  true 
that  every  employment  involves  danger  to  health.  This  applies  to 
those  who  work  with .  their  brains  as  well  as  to  those  who  perform 
manual  labor.  Undue  exposure  to  heat  and  cold  in  the  open  air  may 
be  equally  as  injurious  as  prolonged  confinement  in  poorly  ventilated 
rooms.  Girls  who  are  subject  to  such  unhygienic  conditions  become 
delicate,  anemic,  and  suffer  from  various  nervous  disorders,  and  in 
time  become  unfit  to  assume  the  responsibilities  of  motherhood.  The 
constant  sitting  position,  combined  with  a  bending  forward  assumed 
day  after  day  and  for  hours  at  a  time  by  girls  in  shops,  factories,  and 
oflBces,  engenders  a  pelvic  congestion  which  leads  to  menstrual  disorders 
of  various  types.    . 

Strassmann  calls  attention  to  the  very  large  percentage  of  machine- 
operators  who  suffer  from  pelvic  inflammation.  Occupations  w^hich 
demand  prolonged  standing  bring  their  penalty  in  many  ways.  In  the 
young  girl  whose  pelvis  is  not  fully  developed,  certain  pelvic  deformi- 
ties may  result  which  in  turn  may  give  rise  to  serious  trouble  in  future 
childbirths.  Ivottnitz  has  observed  the  frequency  of  flat  pelves  in 
women  who  were  never  the  subject  of  rickets  but  who  began  at  an 
early  age  to  work  in  weaving  mills.  It  is  a  well-established  fact  that 
preexisting  gynecological  disorders  are  aggravated  by  long  standing. 

Prolonged  and  severe  exertion,  early  in  life,  leads  to  maladies  which 
may  make  women  totally  unfit  for  wives  and  mothers  and  subject  to 
anemic,  nervous,  and  menstrual  disorders.  Overwork  for  one  individual 
may  not  be  overwork  for  another,  but  in  general  every  woman  is  over- 
worked who  toils  by  day  in  shops  and  factories  and  undertakes  to 
perform  the  duties  of  the  home  in  the  early  morning  and  evening  hours. 
While  we  would  not  deny  women  the  privilege  of  work,  we  should  see 
to  it  that  they  do  not  exceed  the  eight-hour-day  limit,  that  they  are 


FORM  OF  CASE  RECORD  21 

not  compelled  to  work  Saturday  afternoons  and  Sundays,  and  that 
every  hygienic  safeguard  is  placed  about  them.  Women  in  the  latter 
weeks  of  pregnancy  should  not  be  permitted  to  work  outside  the  home. 
This,  of  course,  is  possible  only  by  giving  them  compensation  for  the 
loss  of  w^ages  incurred. 

No  considerable  improvement  in  the  influence  of  industrial  life 
upon  the  health  of  women  can  be  looked  for  until  health  comissioners 
are  empowered  to  make  rigid  inspection  and  are  given  the  power  to 
enforce  sanitary  conditions.  This  inspection  should  embrace  the 
home,  the  school,  the  shops,  and  the  factory.  Wherever  women  are 
brought  in  close  contact  with  one  another,  there  is  always  a  call  for 
improvement  in  personal  and  general  hygiene. 

Nationality. — The  Jewish  race  is  said  to  menstruate  early  and  to 
early  reach  the  menopause,  but  the  author  knows  of  no  definite  evidence 
to  this  effect.  The  Caucasian  race  is  more  subject  to  carcinoma,  the 
African  to  fibroids. 

Social  State. — It  is  well  to  inquire  into  the  social  state  of  the  patient 
■ — to  learn  whether  she  is  single,  married,  or  a  widow.  An  early  under- 
standing may  forestall  an  embarrassing  question  as  to  the  sexual 
relations,  and  may  suggest  possible  causes  for  her  complaints.  For 
example,  a  recently  married  woman  complaining  of  leucorrhea  and 
painful  urination  is  suspected  of  being  infected.  The  fact  that  the 
patient  is  single  or  a  widow  should  never  mislead  the  examiner  in  his 
diagnosis;  the  possibility  of  pregnancy  and  venereal  infection  must 
always  be  excluded  by  the  usual  methods  of  examination,  uninfluenced 
by  the  social  state  of  the  patient.  While  the  physician  must  be  alert 
to  these  possibilities,  he  should  exercise  great  tact  and  caution  in  his 
inquiries. 

Number  of  Children  and  Miscarriages. — Frequent  childbearing  and  mis- 
carriages almost  certainly  result  in  some  sort  of  pelvic  ailment.  It 
is  exceptional  for  a  woman  to  give  birth  to  several  children  without 
acquiring  a  pelvic  lesion.  Complaints  dating  back  to  a  childbirth  or 
miscarriage  suggest  the  probable  finding  of  an  inflammatory  lesion, 
a  displacement,  or  a  laceration. 

General  Predisposing  Conditions. — The  condition  of  the  bowels  and 
bladder,  the  cardiovascular,  nervous,  and  respiratory  systems,  should 
be  carefully  inquired  into. 

Not  infrequently  a  pelvic  lesion  is  dependent  upon  a  disorder  of 
the  abdominal  or  thoracic  viscera.  Dysmenorrhea,  leucorrhea,  uterine 
hemorrhage,  and  sterility  may  be  directly  referred  to  a  general  dis- 
turbance. An  excitable  and  overwrought  nervous  system  alone  may 
be  responsible  for  many  of  the  functional  disorders  of  the  pelvic  viscera. 
Regard  for  the  general  condition  of  the  patient  and  a  due  appreciation 
of  the  influence  of  the  general  upon  local  conditions  will  do  much  toward 
eliminating  so-called  "meddlesome  gynecology." 

Family  History. — It  is  improbable  that  heredity  plays  an  important 
role  in  the  etiology  of  pelvic  disorders.  In  tuberculosis,  and  to  a  lesser 
degree  in  carcinoma,  the  influence  of  heredity  should  not  be  under- 


22  HEMORRHAGE  FROM  THE  GENITAL  TRACT 

estimated;  but  in  the  l)enif]:n  tumor  formations,  displacements,  and 
malformations,  heredity  has  little  or  no  influence.  It  is  well  to  inquire 
carefully  into  the  family  history,  but  its  influence  should  not  be  over- 
estimated. 

Previous  Illnesses. — Acute  infectious  diseases,  tuberculosis,  and  all 
chronic  wastinj-;  diseases,  anemias,  and  long-standing  lesions  of  the 
thoracic  and  abdominal  viscera  may  both  originate  and  aggravate 
disorder  in  the  genital  tract. 

General  conditions  have  an  important  bearing  upon  the  pelvic 
viscera,  not  only  in  aggravating  the  disorders,  but  in  actually  originating 
them.  It  therefore  becomes  imperati\-e  to  consider  carefully  all  general 
conditions  in  relation  to  their  possible  bearing  upon  functional  disturb- 
ances and  lesions  of  the  genitalia. 

Present  Complaints. — The  complaints  of  the  patient  will  often  serve 
as  a  suggestion,  but  a  diagnosis  can  never  be  based  upon  subjective 
symptoms  in  the  absence  of  a  physical  examination.  Any  or  all  of 
the  pelvic  disorders  may  exist  without  subjective  symptoms.  On 
the  other  hand,  there  may  be  serious  complaints  on  the  part  of  the 
patient  in  the  absence  of  a  pelvic  lesion.  The  familiar  group  of  symp- 
toms— hemorrhage,  pain,  leucorrhea,  constipation,  and  backache — are 
common  to  many  altogether  dissimilar  lesions  in  the  pelvis.  Little 
reliance  can  be  placed  upon  the  complaints  of  the  patient,  but  the 
diagnosis  must  depend  in  great  part  upon  the  physical  findings.  Symp- 
toms, at  best,  are  only  suggestive  of  a  possible  lesion. 

Menstrual  History. — So  far  the  patient  has  been  considered  from 
the  standpoint  of  the  general  practitioner.  It  is  now  necessary  to 
consider  more  particularly  the  disorders  of  the  genital  organs. 

HEMORRHAGE  FROM  THE  GENITAL  TRACT 

Hemorrhage  from  the  Vulva  Tubal  Menstruation 

Hemorrhage  from  the  Vagina  |         Menstruation  without  Ovaries 


Hemorrhage  from  the  Cervix 
Menstruation 

Time  of  Onset 

Frequency 

Quantity 

Anatomv  of  Menstruating  Uterus 


Uterine  Hemorrhage 
Systemic  Causes 
Local  Causes 

Character  of  Discharged  Blood 
Treatment 


In  diseases  of  women  the  most  significant  of  all  symptoms  is  hemor- 
rhage. While  not  in  itself  diagnostic,  it  is  of  the  greatest  value  as  an 
indication  for  an  immediate  and  searching  physical  examination,  both 
general  and  local.  Hemorrhage  from  the  genitalia  comes  from  the 
vulva,  vagina,  cervix,  body  of  the  uterus,  and  occasionally  from  the 
tubes;  never  from  the  ovary  except  in  the  case  of  a  tuboovarian'hema- 
toma  discharging  its  contents  into  the  uterus — a  most  unusual  event. 

Hemorrhage  from  the  Vulva. — This  is  the  result  of  trauma,  new- 
formations,  ulcerations,  lupus,  cancroid,  and  rupture  of  varicose  veins 
complicating  pregnancy.  The  origin  of  the  bleeding  is  recognized  by 
direct  inspection. 


MENSTRUATION  23 

Hemorrhage  from  the  Vagina. — This  is  due  to  causes  similar  to 
those  already  enumerated.  An  exceptional  cause  lies  in  metastatic 
growths  of  syncytium  (syncytioma  malignum).  The  bleeding  site  is 
readily  disclosed  by  the  vaginal  speculum. 

Hemorrhage  from  the  Cervix. — From  the  vaginal  portion  of  the 
cervix  hemorrhage  follows  immediately  upon  the  delivery  of  the  child 
as  the  result  of  lacerations.  At  the  end  of  the  childbearing  period  the 
most  common  cause  of  hemorrhage  from  the  cervix  is  carcinoma.  Less 
frequent  causes  are  sarcoma,  tuberculosis,  syphilis,  and  erosions. 

Before  considering  the  morbid  conditions  causing  bleeding  from  the 
uterus,  certain  conditions  which  may  be  looked  upon  as  a  physiological 
uterine  hemorrhage  must  be  considered. 

Menstruation. — No  other  organism  loses  so  much  blood  from  the 
uterus  as  does  woman.  Within  certain  ill-defined  limits  this  loss  of 
blood  is  physiological;  hence  it  is  important  to  consider  first  of  all  the 
character  of  the  normal  menstrual  act  before  taking  up  the  discussion 
of  pathological  bleeding  from  the  uterus. 

Time  of  Onset. — ^The  time  of  onset  of  the  menstrual  function  varies 
widely  among  individuals.  Climate  has  much  to  do  with  determining 
the  onset,  and  heredity  has  some  influence.  In  this  country  Engelmann 
found  the  average  age  to  be  fourteen,  in  cold  climates  sixteen,  and  in 
warm  climates  nine  years.  Later  observations  made  by  Engelmann 
led  him  to  the  conclusion  that  early  puberty  is  the  rule  in  Arctic  regions 
rather  than  at  the  equator.  He  observed  that  nutrition  and  habitation 
and  a  lascivious  life,  with  early  and  constant  mingling  of  the  sexes, 
might  appear  to  explain  the  early  puberty  of  the  Eskimo. 

Precocious  Menstruation. — Precocious  menstruation  is  a  condition 
that  occurs  occasionally.  The  earliest  case  occurred  in  Glasgow  at 
four  days  of  age.  Irion  records  a  case  at  seven  days,  and  the  literature 
abounds  in  cases  a  few  weeks  and  months  of  age.  In  nearly  all  these 
cases  the  genitalia  were  abnormally  developed;  there  was  hair  on  the 
pubis,  and  the  breasts  were  often  enlarged.  Precocious  menstruation 
without  premature  development  of  the  menstrual  organs  is  improbable, 
and  when  this  development  is  not  found  the  hemorrhage  should  not 
be  regarded  as  catamenial  unless  it  recurs  at  monthly  intervals.  The 
mother  will  bring  to  the  physician  a  napkin  marked  by  a  red  stain, 
and  will  ask  whether  it  is  possible  that  her  child  is  menstruating. 
Such  stains  may  be  blood  from  a  vulvovaginitis  or  urethritis,  but  are 
more  often  deposits  of  red  urates  or  uric  acid.  City-bred  girls  men- 
struate six  to  twelve  months  earlier  than  girls  living  in  the  country 
(Williams). 

Frequency  of  the  Menstrual  Period. — It  is  often  stated  that  the  normal 
type  is  twenty-eight  days,  but  women  are  rarely  so  regular;  there  is 
usually  a  variation  of  one  or  more  days.  Regularity  in  the  menstrual 
functions  adds  neither  strength  nor  grace.  Women  menstruate  at 
long  or  short  intervals  without  ill-effect,  providing  the  quantity  of 
blood  lost  does  not  materially  lessen  their  strength. 


24  HEMORRHAGE  FROM  THE  GENITAL   TRACT 

Quantity. — The  average  quantity  of  menstrual  blood  lost  in  a  single 
period  is  estimated  at  from  six  to  eight  ounces — the  minimum  two 
and  the  maximum  ten.  Obviously  what  may  be  regarded  as  a  normal 
quantity  for  one  may  be  abnormal  for  another.  A  pletlioric,  well- 
nourished  woman  may  menstruate  freely,  for  eight  days  without  harm, 
while  the  same  loss  of  blood  in  an  anemic  indi\idual  might  seriously 
undermine  her  strength. 

It  is  impractical  to  collect  the  menstrual  blood ;  therefore  the  amount 
of  blood  lost  is  estimated  by  counting  the  number  of  napkins  soiled. 
Xo  exact  information  is  gained  by  this  procedure  because  the  size 
and  quality  of  the  napkins  vary,  and  one  woman  will  tolerate  an  over- 
saturated  napkin,  while  another  will  scarcely  permit  the  staining. 
However,  no  better  means  is  at  command,  and  by  estimating  the  usual 
number  at  fourteen  napkins  in  the  entire  period  a  fair  estimate  of  the 
amount  of  blood  lost  during  the  menstrual  period  can  be  obtained. 

Anatomy  of  the  Menstruating  Uterus. — Kundrat  and  Engelmann  were 
the  first  to  record  anatomical  observations  on  the  menstruating  uterus. 
These  observations  were  made  on  cadavers  in  which  the  endometrium 
of  the  uterine  body  had  undergone  fatty  degeneration  and  the  surface 
epithelium  was  exfoliated. 

Later,  Williams  made  postmortem  examinations  of  twelve  men- 
struating uteri.  Nine  of  the  twelve  patients  died  of  acute  infectious 
diseases.  Like  Kundrat  and  Engelmann,  he  found  fatty  degeneration 
of  the  mucosa  of  the  uterine  body,  and  stated  that  the  entire  mucosa 
down  to  the  musculature  was  exfoliated,  and  that  after  menstruation 
the  mucosa  was  regenerated  from  the  musculature. 

Leopold  recognized  the  observations  of  Kundrat,  Engelmann,  and 
Williams  as  faulty,  in  that  the  changes  in  the  endometrium  as  described 
by  them  might  result  from  the  acute  infections  and  chronic  wasting 
diseases  which  were  the  causes  of  death.  He  carefully  excluded  all 
such  cases  and  selected  those  of  normal  menstrual  type.  He  failed 
to  observe  fatty  degeneration  of  the  mucosa,  but  agreed  that  the  sur- 
face epithelium  was  shed  in  the  menstrual  process.  He  does  not  state 
how  long  after  death  the  sections  were  made,  or  the  method  of  prepar- 
ing the  specimens.  Within  a  few  hours,  certainly  within  twenty-four 
hours  after  death  or  hysterectomy',  the  surface  epithelium  undergoes 
degenerative  changes  and  may  be  wholly  lacking  in  microscopic  sections 
unless  the  tissues  are  immediately  fixed  in  formalin  or  some  other 
fixing  fluid. 

It  was  Moricke  who  first  excluded  the  possibility  of  postmortem 
and  postoperative  changes  in  the  uterus  by  examining  scrapings  from 
the  normal  menstruating  uterus.  He  curetted  and  made  microscopic 
examination  of  forty-five  menstruating  uteri  in  all  stages  of  menstrua- 
tion. In  every  instance  the  surface  epithelium  was  found  intact.  In 
two  additional  cases  Lolilein  reported  similar  findings. 

Westphalen  also  made  a  series  of  examinations  of  scrapings  of  the 
mucosa  during  the  various  stages  of  menstruation.  In  every  case  in 
which  the  mucosa  was  normal  the  entire  membrane  was  well  preserved ; 


MEN  ST  R  UA  TION  25 

in  morbid  conditions  of  the  mucosa  part  or  all  of  the  surface  epithelium 
was  shed.    Mandle  confirmed  these  findings. 

The  most  elaborate  observations  were  made  by  Gebhard  in  Berlin. 
He  not  only  examined  scrapings,  but  also  sections  of  uteri  removed 
during  the  menstrual  period  for  lesions  not  involving  the  endometrium. 

Stages. — He  divides  the  anatomical  changes  into  three  stages: 

The  Stage  of  Premenstrual  Comjestion. — The  capillaries  of  the  mucosa 
are  congested;  a  serous  or  serosanguineous  exudate  infiltrates  the 
stroma  of  the  mucosa,  widening  the  intercellular  spaces;  later  the  blood 
leaves  the  capillaries  and  infiltrates  the  stroma,  gravitating  in  the 
direction  of  least  resistance — i.  e.,  toward  the  uterine  cavity,  and 
forming  a  collection  of  blood  beneath  the  surface  epithelium. 

The  Stage  of  Active  Hemorrhage. — The  blood  is  forced  between  the 
epithelial  cells  into  the  uterine  cavity;  here  and  there  the  epithelium 
is  lifted  from  its  bed,  the  continuity  of  the  surface  is  broken,  and  bits 
of  epithelium  are  accidentally  broken  off  and  carried  with  the  menstrual 
flow.    Blood  may  also  find  its  way  into  the  gland  lumina. 

The  Stage  of  Postmenstrual  Involution. — The  bloodvessels  become  less 
engorged;  blood  is  no  longer  extravasated  into  the  connective-tissue 
spaces;  the  blood  left  in  the  stroma  is  slowly  absorbed;  the  surface 
epithelium  lifted  from  its  bed  resumes  its  former  place,  and  lost  epithe- 
lium is  rapidly  regenerated  from  adjacent  epithelial  surfaces. 

Hitchmann  and  Adler  divide  the  monthly  cycle  into  four  phases: 
First,  the  postmenstruum,  which  corresponds  to  the  normal  endometrium, 
in  which  the  glands  are  small,  regular,  and  round  on  cross-section,  the 
epithelium  narrow  with  large  oval  nuclei,  and  the  connective  tissue  of 
round  and  spindle  cells  densely  packed.  Second,  the  interval  in  which 
the  glands  assume  a  corkscrew-shape,  the  epithelium  is  lengthened  and 
contains  a  superabundance  of  protoplasm.  Third,  the  premenstruum, 
in  which  the  mucosa  becomes  thick  and  velvety,  and  in  which  three 
layers  are  distinguished,  the  superficial,  compact,  and  spongy.  The 
glands  are  irregularly  convoluted,  the  epithelium  is  thrown  into  folds, 
and  presents  feathery  projections.  The  interglandular  spaces  are  filled 
with  large  stroma  cells,  not  unlike  decidual  cells.  Fourth,  the  phase 
of  menstruation  in  which  blood  is  noted  in  the  stroma  and  on  the 
surface,  as  described  above. 

It  will  be  observed  that  these  histological  changes  are  identical  to 
those  found  in  hypertrophic  glandular  endometritis,  and  it  is 
altogether  probable  that  the  menstrual  changes  in  the  endometrium 
are  often  mistaken  for  endometritis — a  fact  so  clearly  brought  out  by 
Hitchmann  and  Adler. 

Nine  hysterectomies  were  performed  by  Dr.  Webster  and  one  by 
the  author  during  the  various  stages  of  menstruation. 

Immediately  upon  removal  the  uterus  was  placed  in  salt  solution, 
then  placed  in  Zenker's  solution  for  twenty-four  hours.  Sections  were 
then  made  from  various  parts  of  the  endometrium,  tubes,  and  cervix; 
they  were  then  carried  through  the  usual  technic  in  preparing  celloidin 
sections. 


26  HEMORRHAGE  FROM  THE  GEXITAL   TRACT 

In  six  cases  examined  by  the  author  the  tubes  showed  no  changes, 
and  the  cervix  was  somewhat  congested.  The  anatomical  changes  char- 
acterizing menstruation  were  confined  to  the  mucosa  of  the  uterine 
body  in  six  cases,  while  in  the  other  three  there  were  similar  changes 
in  the  Fallopian  tubes.  These  observations  establish  the  fact  of  tubal 
menstruation. 

While  knowledge  of  the  physiology  of  menstruation  is  far  from 
exact,  a  number  of  well-established  facts  relating  to  the  anatomy  of 
the  menstruating  uterus  are  known.  Moricke,  Mandle,  Gebhard, 
Herzog  and  others  ha\-e  demonstrated  beyond  dispute  that  men- 
struation is  not  a  shedding  process,  that  the  loss  of  epithelium  is  purely 
accidental  and  limited.  Previous  observations  were  at  fault  in  the 
technic  of  preparing  the  sections,  and  in  the  selection  of  material  which 
had  imdergone  cadaveric  changes  and  degenerative  changes  common 
to  infectious  and  chronic  wasting  diseases. 

Tubal  Menstruation. — It  has  been  the  consensus  of  opinion  that  the 
Fallopian  tubes  do  not  take  part  in  the  menstrual  act.  A  few  cases 
have  been  observed  in  which  blood  collected  in  the  tube  during  men- 
struation, but  it  is  not  proved  that  in  these  cases  the  blood  came  directly 
from  the  mucous  membrane  of  the  tube  and  not  from  the  uterus.  The 
author  has  observed  the  same  histological  changes  during  the  men- 
strual period  in  the  tubes  and  in  the  uterus.  These  changes  were  seen 
in  three  cases  of  the  nine  examined.  From  these  observations  the 
author  is  convinced  that  the  Fallopian  tubes  menstruate  in  a  small 
proportion  of  cases. 

In  the  three  instances  referred  to  the  identical  changes  were  found 
in  the  mucous  membrane  of  the  tube  that  were  found  in  the  endome- 
trium. The  tubes  were  perfectly  normal  in  every  respect.  J.  M.  Baldy, 
of  Philadelphia,  observed  a  complete  inversion  of  the  uterus  in  which 
the  endometrium  failed  to  bleed  during  the  menstrual  period,  but  at 
this  time  blood  escaped  from  the  uterine  ends  of  either  tube.  J.  Riddle 
Goffe  observed  blood  issuing  from  the  tubes  during  menstruation,  and 
is  of  the  opinion  that  the  tubes  occasionally  menstruate.  That  the 
Fallopian  tubes  menstruate  in  a  small  proportion  of  cases  would 
appear  evident  from  these  clinical  and  histological  observations. 

Menstruation  without  Ovaries. — Menstruation  has  been  know^n  to 
appear  at  regular  intervals  and  for  a  considerable  period  of  time  after 
the  removal  of  both  ovaries.  The  theories  advanced  in  explanation 
of  this  phenomenon  are  by  no  means  convincing. 

Supernumerary  and  Accessory  Ovaries. — This  will  probably  account 
for  a  large  proportion  of  cases.  Meriel  found  aberrant  ovarian  tissue 
in  4  per  cent,  of  female  bodies  of  all  ages.  These  bodies  varied  in  size 
from  that  of  a  millet-seed  to  a  cherry,  and  were  found  near  th6  ana- 
tomical ovary  or  remote  from  the  parent  ovary  in  the  broad  ligament, 
ovarian  ligament,  pelvic  pouches,  under  the  peritoneum,  adjacent  to 
the  ureter  or  adherent  to  the  omentum  or  intestine. 

Persistence  of  the  menstrual  cycle  by  virtue  of  an  established  "habit." 


UTERINE  HEMORRHAGE  27 

Unknown  Causes. — There  is  strong  presumptive  evidence  that  the 
ovaries  are  not  essential  to  menstruation;  that  other  factors,  as  yet 
unknown,  may  operate  in  exciting  the  menstrual  flux  in  the  absence 
of  the  ovaries.  There  is  much  need  for  further  investigation  of  the 
subject. 

Uterine  Hemorrhage. — Text-books  discuss  menorrhagia  and  metror- 
rhagia— the  former  term  applies  to  an  abnormal  increase  in  the  men- 
strual flow,  and  the  latter  to  an  intermenstrual  flow.  These  terms 
should  be  eliminated  from  common  usage  because  of  the  impossibilit}' 
of  distinguishing  between  the  two  in  many  cases.  The  one  so  often 
merges  into  the  other  in  such  a  manner  as  to  render  impossible  a  dis- 
tinction between  a  menstrual  and  an  intermenstrual  flow.  Then,  too, 
they  are  dependent  upon  the  same  general  causes.  For  the  sake  of 
simplicity  and  exactness,  both  are  here  included  under  the  general 
head  of  uterine  hemorrhage. 

Systemic  Causes. — Hemorrhage  from  the  uterus  may  occur  as  the 
result  of  general  systemic  disturbances  in  the  absence  of  a  local  lesion. 

i^NEMiA  AND  Plethora. — Anemia  and  plethora  may  cause  hemor- 
rhage— anemia  by  reason  of  the  low  specific  gravity  of  the  blood  and 
its  diminished  coagulability,  and  plethora  from  high  vascular  pressure. 
Chlorosis  is  the  exception  among  the  anemias,  in  that  the  menstrual 
flow  is  lessened  or  absent.  Anemia  is  commonly  spoken  of  as  the  result 
of  uterine  hemorrhage,  when,  as  a  matter  of  fact,  it  is  not  seldom  the 
underlying  cause. 

The  author  operated  upon  a  case  diagnosticated  b}'  Dr.  B.  W.  Sippy 
as  splenic  anemia,  in  which  a  perfectly  normal  uterus  bled  excessively 
every  three  weeks.  Removal  of  the  spleen  resulted  in  a  rapid  restoration 
of  the  blood  and  the  disappearance  of  the  uterine  hemorrhage.  Failure 
to  check  uterine  hemorrhage  by  ergot  and  curettage  is  frequently 
accounted  for  by  failure  to  recognize  possible  general  causes. 

Purpuric  Conditions. — All  purpuric  conditions  may  be  accompanied 
by  hemorrhage  from  the  uterus  as  well  as  from  other  parts  of  the  body. 

Infectious  Diseases. — The  specific  infectious  diseases  may  be  com- 
plicated by  hemorrhage  from  the  uterus  brought  about  by  blood  and 
vascular  changes,  and  acquired  insufficiency  of  the  uterine  musculature. 

Emotion. — It  is  said  that  emotion  will  excite  a  hemorrhage  from 
the  uterus.  The  accuracy  of  this  statement  is  doubtful;  in  his  own 
experience  the  author  has  never  seen  the  uterus  bleed  after  a  period 
of  mental  excitement  in  which  there  was  not  found  a  pathological 
lesion  to  account  for  the  loss  of  blood.  The  mental  disturbance  serves 
only  as  an  exciting  cause  of  the  hemorrhage,  but  without  a  pathological 
lesion  there  would  be  no  hemorrhage. 

Passive  Congestion. — Whatever  impedes  the  return  flow  of  blood 
from  the  uterus  will  bring  about  passive  congestion  in  that  organ,  which 
in  turn  may  result  in  hemorrhage.  In  this  category  may  be  mentioned 
displacements  of  the  uterus,  diseases  of  the  heart,  lungs,  liver,  kidney, 
and  spleen,  abdominal  tumors,  ascites,  and,  lastly,  chronic  constipation. 

Many  an   otherwise   insignificant  local  lesion,   such  as   a  mucous 


28  HEMORRHAGE  FROM  THE  GENITAL  TRACT 

polyp,  would  probably  cause  little  or  no  bleeding  were  it  not  for  the 
passive  congestion  of  the  pelvis  brought  about  by  such  factors. 

Local  Causes. — Subina'olution. — Subinvolution  of  the  uterus,  the 
result  of  postabortive  and  puerperal  infection,  may  be  regarded  as 
the  most  prolific  source  of  pelvic  disorders  in  the  female.  It  is  the 
starting  point  of  many  displacements  and  inflammations  which  eventu- 
ate in  uterine  hemorrhage.  The  uterus  is  enlarged  in  all  its  diameters, 
and  is  deeply  congested.  Such  an  organ  rarely  maintains  its  position 
because  of  an  increase  in  weight  and  a  lack  of  support  from  the  ligaments 
and  pelvic  floor,  which  have  been  stretqhed  and  torn  in  labor.  The 
usual  factors  in  the  development  of  subinvolution  are  early  rising  from 
childbed,  traumatisms  in  labor  and  infection  following  labor,  and 
abortion.  In  this  connection  it  is  to  be  remembered  that  retained 
placental  tissue  will  result  in  subinvolution  of  the  uterus,  and  may 
remain  organically  attached  to  the  uterus  for  days,  months,  and  even 
years,  keeping  up  irregular  hemorrhages. 

The  essential  factor  in  the  causation  of  hemorrhage  from  a  sub- 
involuted  uterus  lies  in  insuflEiciency  of  the  musculature  of  the  myo- 
metrium rather  than  in  the  endometrium. 

Endometritis. — Endometritis  is  commonly  recognized  by  the  symp- 
toms— hemorrhage,  pain,  and  leucorrhea.  One  or  all  of  these  symptoms 
may  be  absent,  and  the  diagnosis  must  finally  rest  upon  the  micro- 
scopic examination  of  scrapings  from  the  endometrium.  Indeed,  a  posi- 
tive diagnosis  of  endometritis  can  be  made  only  by  the  microscope.  When 
hemorrhage  exists  it  is  usually  in  the  form  of  an  increase  in  the  menstrual 
flow — rarely  as  an  intermenstrual  flow.  Olshausen  has  described  a 
lesion  which  he  calls  fungus  endometritis,  and  bases  his  clinical  diagnosis 
upon  the  presence  of  hemorrhage  in  the  absence  of  pain  and  with  little 
or  no  leucorrhea.  The  endometrium  is  greatly  thickened  and  thrown 
into  folds  and  fungous-like  masses,  which,  under  the  microscope,  are 
seen  to  consist  of  a  meshwork  of  enlarged  and  greatly  distended  glands, 
with  but  little  interglandular  connective  tissue.  Another  variety  of 
endometritis,  usually  resulting  in  a  profuse  menstrual  flow,  is  the 
polypoid.  The  author  believes  that  hemorrhage  is  seldom  the  direct 
result  of  endometritis  but  rather  of  a  deeper  seated  lesion;  one  that 
has  engaged  the  attention  of  gynecologists  in  the  past  decade.  (See 
Muscular  Insufficiency.) 

Para-uterine  Inflammations.  —  Para-uterine  inflammations  are 
usually  associated  with  inflammation  of  the  uterus,  but  may  in  them- 
selves provoke  uterine  bleeding.  The  author  has  repeatedly  drained  a 
pelvic  abscess  without  curetting  the  uterus,  and  has  seen  the  hemor- 
rhages from  the  uterus  disappear  with  the  subsidence  of  the  parauterine 
exudate. 

Mucous  Polyps. — Mucous  polyps  of  the  uterus  are  generally  of 
inflammatory  origin.  Some  authors  believe  them  to  be  invariably  of 
inflammatory  origin,  while  all  admit  that  they  are  in  large  part  so. 
Polyps  generally  produce  prof  useness  of  the  periods,  though  hemorrhage 
is  not  an  invariable  symptom,  and  their  presence  may  be  accidentally 


UTERINE  HEMORRHAGE  29 

discovered  by  the  curet  or  after  the  removal  of  the  uterus  for  other 
reasons. 

Uteeine  Fibroids.— In  general,  it  may  be  said  that  uterine  fibroids 
of  whatever  variety  can  only  cause  hemorrhage  from  the  uterine  cavity 
when  the  tumor  involves  the  endometrium.  Fibroids  rarely  bleed; 
the  hemorrhage  comes  from  the  endometrium. 

Sampson  has  made  most  interesting  observations  on  the  blood 
supply  of  fibroid  tumors  of  the  uterus  and  has  drawn  certain  practical 
deductions  as  to  the  cause  of  hemorrhage  in  these  cases.  The  veins 
were  injected  with  gelatin  containing  ultramarine  blue  and  the  arteries 
with  gelatin  colored  with  Venetian  red.  In  about  half  the  cases  the 
injection  consisted  of  gelatin  and  bismuth  for  the  purpose  of  making 
a;-ray  examinations. 

By  means  of  the  arterial  injections,  Sampson  was  able  to  demonstrate 
the  arterial  blood  suppl}^  in  all  but  a  few  of  the  smaller  tumors.  In  large 
tumors  the  arteries  were  often  enlarged  and  apparently  increased  in 
number.  Not  infrequently  the  large  tumors  were  more  vascular  than 
the  surrounding  musculature.  The  arterial  system  of  the  tumors 
appeared  to  be  of  two  chief  types  of  arrangement;  there  being  a  diffuse 
distribution  of  intrinsic  vessels,  extending  in  all  directions  within  the 
tumor  and  a  marked  development  of  arterial  trees  with  communicating 
branches  and  roots. 

The  injected  veins  showed  the  tumor  to  be  poor  in  veins  and  the 
endometrium  rich  in  veins.  The  blood  lost  in  uterine  fibroids,  accord- 
ing to  Sampson,  largely  comes  from  the  venous  plexus  surrounding  the 
tumor.  One  or  more  branches  of  the  arcuate  arteries  of  the  uterus  sup- 
ply the  tumor  and  are  called  nutrient  arteries;  the  tumor  is  enveloped 
by  these  branches  and  penetrated  by  them.  Arterioles  in  the  tumor 
and  immediately  surrounding  it  may  communicate;  this  Sampson 
believes  to  be  a  secondary  development. 

Fibrous  Polyps  of  Cervix. — The  author  has  observed  a  number 
of  cases  of  postclimacteric  hemorrhage  caused  by  fibrous  polyps  of 
the  cervix.  It  appears  that  such  polyps  are  prone  to  develop  at  this 
time  of  life. 

Carcinoma  and  Sarcoma. — One  of  the  earliest  symptoms  of  cancer 
and  sarcoma  of  the  uterus  is  hemorrhage.  Yet  these  growths  may  be 
far  advanced  before  hemorrhage  or  any  other  symptom  is  manifest. 
For  this  reason  malignant  diseases  of  the  uterus  are  often  not  observed 
in  time  to  effect  a  radical  cure.  When  hemorrhage  does  make  its 
appearance  it  is  too  often  looked  upon  as  an  irregularity  of  the  men- 
opause. The  statistics  in  carcinoma  of  the  uterus  would  he  greatly  bettered 
if  all  hemorrhages  occurring  at  the  time  of  the  menopause  and  after  this 
period  were  viewed  with  suspicion,  and  the  cause  sought  for,  rather  than 
that  all  irregidarities  be  ascribed  to  the  menopause. 

Syncytioma  Malignum. — There  is  a  malignant  growth  to  which 
only  a  brief  reference  is  here  necessary.  It  is  usually  called  syncytioma 
malignum,  and  is  a  malignant  degeneration  of  placental  tissue.  Hemor- 
rhage is  the  earliest  symptom,  and  it  may  be  laid  down,  as  a  rule, 


30  HEMORRHAGE  FROM   THE  GENITAL   TRACT 

that  when  an  irreguhir  hemorrhage  follows  late  upon  childbirth,  hydatid 
mole,  or  abortion,  the  possibility  of  malignant  degeneration  of  placental 
tissue  must  be  borne  in  mind.  The  diagnosis  can  only  be  determined 
by  an  exploratory  curettage  and  microscopic  examination  of  the 
scrapings,  together  with  a  consideration  of  the  clinical  course.  (See 
Chapter  X.) 

Cystic  Degeneration  of  the  Ovaeies. — This  is  an  occasional 
cause  of  uterine  hemorrhage.  Kelly  says  that  hemorrhages  from  the 
uterus  of  ovarian  origin  have  been  known  to  prove  fatal.  On  several 
occasions  the  author  has  checked  uterine  bleeding  by  resecting  cystic 
ovaries  without  curetting  the  uterus  or  in  any  way  directly  altering 
its  conditions.  Such  cysts  of  the  ovary  commonly  develop  from  the 
corpus  luteum. 

Pelvic  Hematoma. — What  has  been  said  of  pelvic  inflammatory 
exudates  will  apply  to  accumulations  of  blood  within  the  pelvis.  When 
the  blood  is  evacuated  the  hemorrhages  from  the  uterus  are  often  seen 
to  disappear. 

Obstetrical  Causes. — It  is  necessary  only  to  refer  to  placenta  proevia, 
hydatid  mole,  p)remat,ure  detachment  oj  the  placenta,  and  ectopic  pregnancy 
as  causes  of  uterine  hemorrhage. 

When  hemorrhage  occurs  during  or  immediately  after  the  third 
stage  of  labor  it  is  possible  that  placental  tissue  is  retained  in  the 
uterus,  or  that  the  uterus  is  relaxed  from  fatigue  and  over- 
stretching. 

Improbable  as  it  may  seem,  death  from  hemorrhage  rarely  follows 
rupture  of  the  uterus,  but  it  is  more  likely  to  occur  from  subsequent 
infection. 

Pathological  Menstruation. — The  persistence  of  menstruation 
during  pregnancy  should  be  regarded  as  a  morbid  condition  and  not 
as  a  perverted  physiological  type,  as  it  is  generally  thought  to  be. 
The  author  believes  that  there  is  a  pathological  lesion  in  every 
instance  to  account  for  the  loss  of  blood. 

Montgomery  observed  a  case  in  which  there  was  a  profuse  hemor- 
rhage at  the  time  of  the  first  menstrual  periotl  following  conception. 
The  patient  learned  to  regard  the  hemorrhage  as  evidence  of  her 
pregnancy.  Baudelocque  and  Deventer  reported  cases  in  which  the 
menses  only  appeared  during  pregnancy  and  ceased  at  its  termina- 
tion. The  hemorrhage  may  appear  at  any  month  of  pregnancy, 
but  with  greater  frequency  in  the  early  months.  In  all  such  cases 
great  caution  should  be  exercised  in  the  diagnosis  of  the  cause  of  the 
hemorrhage.  Before  it  can  be  regarded  as  menstrual  blood  a  most 
searching  examination  must  be  made  for  the  purpose  of  excluding 
such  possible  causes  as  placenta  pr£evia,  double  uterus,  fibroids, 
carcinoma,  mucous  polyps,  and  ectopic  pregnancy. 

Arteriosclerosis. — Arteriosclerosis  alone  has  been  held  responsible 
for  uncontrollable  uterine  hemorrhage  by  Herman,  Martin,  Reinecke, 
and  Kiistner.  This  cannot  be  wholly  sustained,  because  in  none  of 
their  cases  is  there  a  record  of  having  excluded  other  possible  causes 


UTERINE  HEMORRHAGE  31 

lying  beyond  the  uterus.  Reinecke  and  Martin  performed  hysterectomy 
in  thirteen  cases  for  the  control  of  hemorrhage,  and  in  all  the  removed 
uteri  the  arteries  were  found  sclerosed;  but  they  did  not  exclude  the 
possibility  of  obstruction  to  the  return  circulation  from  such  causes 
as  diseases  of  the  heart  and  lungs,  thrombosis  of  the  venous  trunks, 
and  portal  congestion  from  whatever  cause.  The  point  is  that  in  the 
light  of  twelve  cases  reported  by  von  Kahlden,  Popoff,  Herxheimer, 
and  Dietrich,  and  the  one  by  the  author,  arteriosclerosis  yer  se  is  alone 
insufficient  to  cause  a  hemorrhagic  infarction  of  the  uterine  tissues  or 
hemorrhage  into  the  uterine  cavity.  In  the  eight  cases  reported  by 
von  Kahlden  the  postmortem  findings  showed  anatomical  hindrances 
to  the  general  circulation  in  every  case.  There  was  pneumonia  in 
two  of  the  cases,  pulmonary  emphysema  and  bronchitis  in  three  cases, 
cancerous  infiltration  of  the  lungs  and  liver  in  one  case,  pulmonary 
infarcts  in  another,  and  in  four  of  the  eight  cases  there  were  cardiac 
lesions.  In  the  case  of  Popoff  there  were  granular  nephritis  and  heart 
thrombi,  pleural  effusion,  and  infarction  of  the  lung  and  brain.  In 
Herxheimer's  case  there  was  an  hypertrophied  heart  and  thrombi  in 
the  left  ventricle  and  right  auricle,  granular  nephritis,  and  atheroma 
of  the  aorta.  In  the  author's  case,  hemorrhage  did  not  occur  until 
there  was  an  additional  obstruction  to  the  circulation  caused  by  the 
plugging  of  the  uterine  artery.  It  is,  therefore,  not  conclusively 
demonstrated  that  arteriosclerosis  can  in  itself  be  the  cause  of  uterine 
hemorrhage.  It  would  appear  that  there  must  be  additional  causes 
for  obstruction,  such  as  were  found  in  the  recorded  cases. 

In  the  so-called  "apoplexia  uteri,"  it  is  probable  that  the  hemor- 
rhages are  not  caused  by  the  rupture  of  the  bloodvessels,  but  rather 
are  due  to  capillary  oozing.  This  would  account  for  the  hemorrhagic 
infiltration  being  so  removed  from  the  sclerosed  vessels  in  the  cases  of 
von  Kahlden. 

Etiology. — Respecting  the  etiology  of  arteriosclerosis  of  the  uterine 
vessels  and  hemorrhagic  infarction  of  the  uterus,  little  can  be  said. 
Age  varies  within  the  limits  of  fifty  and  eighty-seven  years.  Pregnancy, 
menstruation,  and  inflammation  of  the  uterus  have  some  bearing 
upon  the  etiology.  The  causes  of  arteriosclerosis,  i.  e.,  alcoholism, 
chronic  malaria,  chronic  lead  poisoning,  syphilis,  etc.,  that  obtain 
elsewhere  in  the  body,  apply  likewise  to  the  uterus. 

Frequency. — It  is  not  unlikely  that  arteriosclerosis  of  the  uterine 
arteries  and  hemorrhagic  infarction  of  the  uterus  are  often  overlooked 
in  clinical  and  postmortem  examinations.  It  is  probable  that  many 
cases  of  so-called  "senile  endometritis"  and  "hemorrhagic  metritis  of 
the  menopause"  are  in  reality  hemorrhagic  infarction  of  the  uterus, 
and  have  as  an  underlying  factor  arteriosclerosis  and  calcareous 
degeneration  of  the  uterine  vessels.  The  fact  that  these  cases  occur 
in  advanced  years,  that  they  may  not  be  associated  with  leucorrhea, 
and  that  no  cause  may  be  found  for  the  hemorrhages,  either  by  clinical 
examination  of  the  uterus  and  adnexa  or  microscopic  examination  of 
scrapings  from  the  endometrium,  would  be  strong  evidence  in  favor 


32  H.EMORRHAGE  FROM  THE  GENITAL  TRACT 

of  the  \it'\v  that  these  cases  are  not  infrequently  hemorrhagic  infarcts 
of  the  uterus  and  that  the  priman^  lesion  lies  in  the  bloodvessels. 

Diagnosis.— V\\\en  there  is  no  demonstrable  cause  for  the  hemorrhage 
the  cases  are  usually  called  endometritis.  If  an  exploratory  curettage 
is  made  with  negative  findings,  the  indefinite  diagnosis  of  metritis 
will  probably  be  given,  particularly  when  the  uterus  is  of  dense  con- 
sistency and  uniformly  increased  in  size.  It  is  possible  that  the  increase 
in  the  connective  tissue  of  the  myometrium  may  interfere  with  the  cir- 
culation, but  it  is  altogether  certain  that  in  many  cases  the  primary 
cause  lies  in  the  walls  of  the  bloodvessels,  and  the  hyperplasia  of  the 
uterus  is  secondary.  It  is  altogether  probable  that  arteriosclerosis 
of  the  uterine  vessels  may  exist  without  sj^mptoms,  and,  as  stated, 
there  probably  must  be  some  additional  obstruction  to  the  return 
circulation  in  order  to  cause  hemorrhage.  This  event  alone  is  suggestive 
of  the  lesion.  The  clinical  diagnosis  is,  therefore,  at  best  uncertain. 
If  hemorrhage  occurs  in  the  climacterium  or  near  the  time  of  the 
menopause,  and  no  local  cause  for  the  hemorrhage  can  be  found,  either 
in  the  presence  of  newgrowths  of  the  uterus  and  adnexa,  in  the  position 
of  the  uterus;  or  in  the  microscopic  examination  of  the  uterine  scrapings, 
then  it  is  fair  to  .presume  that  arteriosclerosis  of  the  uterine  arteries 
exists.  If,  in  addition  to  this,  there  is  found  arteriosclerosis  of  the 
peripheral  arteries  of  the  body,  and  there  exists  a  disease  of  the  viscera 
to  account  for  an  obstruction  in  the  return  circulation  from  the  pelvis, 
then  it  is  fair  further  to  presume  that  a  hemorrhagic  infarction  of  the 
uterus  is  present,  and  that  the  uterine  hemorrhages  are  due  to  a  hemor- 
rhage into  the  tissues  and  cavity  of  the  uterus.  It  is  not  probable 
that  the  sclerosed  vessels  will  be  found  in  the  scrapings,  because  they 
commonly  lie  in  the  outer  half  of  the  uterine  musculature.  Caution 
must  be  exercised  not  to  mistake  the  compressed  glands  for  cancer 
nests. 

Syphilitic  Uterine  Hemorrhage. — Jaworskl  mentions  eight  cases 
of  obstinate  uterine  hemorrhage  of  sjqjhilitic  origin.  There  is  a  sj^phi- 
litic  angiosclerosis  of  the  uterus  marked  by  a  hardening  of  the  uterus 
which  may  spread  to  the  whole  organ  and  even  to  the  parametric 
tissues.  As  a  rule,  the  bloodvessels  are  affected  and  the  syphilitic 
arteritis  of  tertiary  syphilis  may  be  the  most  prominent,  and  indeed  it 
may  be  the  only  uterine  change.  The  loss  of  elasticity  of  the  uterine 
tissue,  together  with  the  hardening  of  the  uterine  vessels,  may  give  rise 
to  frequent,  copious,  and  obstinate  bleeding  from  the  uterus,  both  at 
the  menstrual  period  and  in. any  hyperemia  of  the  uterus.  He  gives 
notes  of  five  of  his  cases.  In  the  first  of  these  the  hemorrhages  had 
been  excessive  during  three  years,  and  three  "cures"  wdth  saline  baths 
and  peat  baths  had  done  no  good,  nor  had  curetting  of  the  uterus. 
At  this  time  the  man  with  whom  the  patient,  an  unmarried  woman, 
cohabited  came  under  treatment  for  tabes.  Antisyphilitic  treatment 
was  now  given  the  woman,  with  the  result  that  the  abnormal  hemor- 
rhages altogether  ceased,  and  the  uterus  became  smaller  and  also 
normal  in  consistency. 


UTERINE  HEMORRHAGE  33 

The  symptoms  which  suggest  tertiary  syphilis  of  the  uterus  are  not 
characteristic.  The  most  constant  symptom  is  the  occurrence  of 
uterine  hemorrhages  which  resist  local  treatment  and  the  next  in  fre- 
quency is  an  olfstinate,  offensive,  mucopurulent  discharge.  The  loss 
of  blood  always  results  in  severe  anemia,  which  may  even  proceed  as 
far  as  cachexia.  The  uterus  is  usually  increased  in  bulk,  occasionally 
it  is  atrophic,  its  tissue  is  lacking  in  normal  elasticity,  and  may  be  hard, 
sometimes  almost  of  a  cartilaginous  consistency.  A  history  of  habitual 
abortion,  usually  at  the  same  period  of  pregnancy,  would  be  a  great 
help  to  diagnosis.  In  the  ulcerative  forms  of  late  syphilis  of  the  uterus 
carcinoma  of  the  uterus  may  be  simulated. 

Menopause. — Finally,  it  may  he  said  .thai  the  popular  impression  tliat 
the  flow  is  increased  in  the  climacterium  leads  to  disastrous  consequences. 
No  increase  in  the  menstrual  flow  at  the  time  of  the  climacterium  should  he 
regarded  as  normal  or  of  no  clinical  importance.  A  searching  examination 
is  imperative. 

Character  of  Discharged  Blood. — The  character  of  the  discharged 
blood  varies  not  only  in  amount,  but  in  color  and  consistency;  and 
from  these  characteristics  something  may  be  inferred  as  to  the  origin  of 
the  hemorrhage.  The  menstrual  blood  is  usually  thin  and  of  a  bright 
red  to  a  dark  brown  color.  Coagulation  is  hindered  by  the  alkaline 
reaction  of  the  uterine  secretions.  Coagulated  menstrual  blood  is 
always  abnormal. 

Coagulation  of  the  blood  may  occur  in  endometritis,  uterine  fibroids, 
carcinoma,  polyps,  and  abortion.  When  the  blood  is  of  a  dark,  brownish- 
red  color  it  is  inferred  that  the  passage  of  the  blood  has  been  obstructed, 
giving  time  for  coagulation  within  the  uterine  cavity.  When  mucus 
is  intimately  mixed  with  the  blood  it  indicates  an  involvement  of  the 
cervix  from  cervical  catarrh,  polyp,  carcinoma,  or  sarcoma. 

Blood  of  a  syrupy  consistency  is  supposed  to  have  remained  a  long 
time  in  the  uterine  cavity.  Tissue  fibers  mixed  with  the  blood  suggest 
the  presence  of  degenerated  newgrowths. 

Treatment  of  Uterine  Hemorrhage. — In  the  treatment  of  uterine 
hemorrhage,  the  fact  must  not  be  overlooked  that  certain  conditions 
remote  from  the  pelvis  may  be  the  essential  or  contributing  factors  in 
the  causation  of  uterine  hemorrhages,  and  therefore  call  for  systemic 
treatment.  Anemia,  plethora,  purpuric  conditions,  diseases  of  the 
heart,  lungs,  kidneys,  and  spleen,  chronic  constipation,  all  may  induce 
excessive  bleeding  at  the  menstrual  period,  and  the  treatment  should 
be  directed  to  these  conditions.  The  treatment  of  uterine  hemorrhage 
is  essentially  the  removal  of  the  cause  and  is  first  medicinal,  second 
mechanical,   third   surgical. 

Medicinal  Treatment. — For  the  control  of  uterine  bleeding  the  drug 
p)ar  excellence  is  ergot.  The  physiological  effect  of  ergot  is  to  produce 
contraction  of  the  uterine  bloodvessels  and  muscle  fibers.  Hence  it 
is  chiefly  applicable  to  atonic  conditions  of  the  uterus  associated  with 
loss  of  blood.  It  finds  its  greatest  applicability  in  the  hemorrhages 
following  abortions  and  labor  due  to  relaxation  of  the  uterine  muscu- 


34 


HEMORRHAGE  FROM  THE  GENITAL  TRACT 


lature  and  will  also  promote  involution  of  a  subinvoliited  uterus  of 
recent  development.  Where  the  uterine  musculature  is  degenerated  or 
embarrassed  by  an  excess  of  connective  tissue,  as  in  chronic  metritis, 
ergot  will  have  little  effect  in  stimulating  the  contractions  of  the  uterus. 
The  fluidextract  of  ergot,  given  by  mouth  in  10-minim  to  1-dram 
doses,  will  produce  results  in  ten  to  twenty  minutes.  When  there  is 
need  for  more  prompt  action,  ergotol  in  5-  to  30-minim  doses  may 
be  given  hypodermically. 

Hydrastis  acts  upon  the  bloodvessels  and  musculature  in  the  same 
manner  as  ergot  and  may  be  given  in  equal  doses  alone  or  in  com- 
bination with  ergot. 

Styptol  and  stypticin  are  extolled  as  uterine  sedatives  and  styptics. 
The  author  has  not  had  as  good  results  with  these  remedies  as  with 
ergot  and  hydrastis.  They  are  given  in  2-  to  4-grain  doses,  three 
or  four  times  daily.  In  the  control  of  excessive  menstruation  they 
have  some  value  and  are  also  credited  with  ha\ing  some  sedative 
action  in  relieving  pain. 

Viburnum  prunifolium,  in  doses  of  ^  to  2  drams,  has  found  favor 
particularly  in  the  establishment  of  the  normal  menstrual  flow. 

Adrenalin  is  said  to  have  a  controlling  influence  over  the  menses. 
The  dose  is  10  to  15  drops  of  a  toVo  solution,  given  four  times  a  day. 

Calcium  chloride  may  be  given  throughout  the  entire  month  in 
doses  of  5  grains  after  each  meal.  During  the  menstrual  period  the 
same  dose  may  be  repeated  at  intervals  of  two  hours. 


I^ — Calcii  chlorid 

Gh'cerini 

Sig. — Teaspoonful  three  times  daity. 

I^ — Fl.  ext.  ergotie 

Sig. — Half -teaspoonful  every  four  hours. 


q.  s.  ad 


oiv 


31V 


20  j 
120 


120  Ice. 


oiij 

oj 

oj 


Calcii  chlorid 

Ergotin 

Hydrastinin 

Div.  iu  caps.  no.  xxx. 

Sig. — One  capsule  every  four  to  six  hours. 

I^ — Stj-pticini gr.  xl 

Ergotae gr-  xl 

Div.  in  caps.  xx. 

Sig. — One  capsule  everj'^  four  hours. 


gi-.  vn 
gi-.  xxx 
gi-.  iii 


6} 


'Bf — Hj'drastinse  hydrochlorid 

Ergotin  (^Merck) 

Ext.  nucis  vomicae 

Div.  in  caps.  no.  x\-. 

Sig. — One  capsule  every  three  hours. 

I^ — Desic.  th\Toid . 

Div.  in  caps.  no.  xx. 

Sig. — One  capsule  five  times  daily. 

I^ — Ergotin 5ss 

Strj^chninse  sulph gr.  ss 

Ext.  cannabis  indica) gr.  x 

Div.  in  caps.  no.  xxx. 

Sig. — One  capsule  every  four  houi's. 


21592 
2  592 


1454 

1  944 

194 


1032 
648 


UTERINE  HEMORRHAGE  35 

I^ — Ergotinse, 

Stypticini, 

Hydrastininse aa       5ss  2| 

Fiat  capsulaj  no.  xxx. 

Sig.— One  capsule  every  four  to  six  hours. 

I^— Ergotin      . 5ss  2| 

Ext.  nucis  vomic gr.  vi  0|4 

Fiat  capsulse  no.  xxx. 

Sig. — One  capsule  every  four  to  six  hom's. 

•  Much  has  been  written  on  the  use  of  pituitrin  in  the  management 
of  uterine  hemorrhage  of  obstetrical  origin,  but  as  yet  the  remedy  has 
not  been  extensively  used  in  gynecological  conditions.  Bab  has  had 
success  in  the  control  of  hemorrhages  due  to  metritis,  endometritis 
and  pelvic  inflammation.  The  dose  was  2  or  3  c.c.  of  pituitrin  injected 
subcutaneously  and  repeated  on  several  successive  days. 

The  a'-rays  have  been  effectively  applied  to  climacteric  hemorrhages 
of  metritic  origin. 

While  employing  the  remedies  mentioned  the  beneficent  effect  of  rest 
must  not  be  overlooked.  Rest  is  the  first  and  most  essential  measure  to 
employ  for  the  control  of  uterine  hemorrhage.  In  girls  who  flow  exces- 
sively it  is  well  to  enjoin  rest  throughout  each  menstrual  period  until 
the  flow  is  regulated.  This  precautionary  measure  alone  will  often 
suffice  for  a  cure. 

.Mechanical  Treatment. — When  the  loss  of  blood  is  excessive  or 
does  not  respond  to  medicinal  treatment  and  rest,  mechanical  means 
must  be  resorted  to  for  control  of  the  bleeding.  The  following  measures 
are  in  general  use. 

Vaginal  Packs. — Vaginal  packs,  consisting  of  strips  of  plain  surgical 
gauze,  are  used  to  pack  the  vagina  tightly.  The  packing  is  done  through 
a  bivalve  or  trivalve  speculum,  using  a  dressing  forceps  for  the  purpose. 
Instead  of  surgical  gauze,  lambs'  wool  or  absorbent  cotton  may  be  used, 
but  not  so  eftectively. 

Uterine  Packs. — Uterine  packs  are  rarely  used  except  in  postabortive 
and  postpartum  hemorrhages.  Sterile  gauze  in  long  strips  is  packed 
tightly  into  the  uterus  from  the  fundus  down.  This  pack  is  allowed 
to  remain  for  forty-eight  hours.  Strict  surgical  cleanliness  must  be 
enforced  in  the  procedure. 

Hot  Vaginal  Douches. — Hot  vaginal  douches  are  of  special  value  in 
hemorrhages  associated  with  pelvic  congestion.  The  patient  should 
be  placed  in  the  dorsal  position.  A  Kelly  pad  or  bed-pan  will  serve  to 
collect  the  douche  water.  Not  less  than  two  gallons  of  water  should  be 
used,  at  a  temperature  of  112°  to  120°  F.  These  douches  should  be 
repeated  once  every  four  to  twelve  hours. 

Hot  Intra-uterine  Douches. — Hot  intra-uterine  douches  have  been 
used  in  postabortive  hemorrhages,  but  they  have  a  limited  field  of  use- 
fulness and  may  do  harm  is  dislodging  emboli,  in  perforating  the  uterus, 
and  in  washing  the  fluid  through  the  tubes  into  the  abdominal  cavity. 

Ice-bags.  —  Ice-bags  placed  over  the  abdomen  and  lumbosacral 
region  are  of  service  when  the  hemorrhages  are  not  excessive. 


36  HEMORRHAGE  FROM  THE  GEXITAL   TRACT 

Intra-uterine  Applications. — Intra-iiterine  applications  of  styptics 
are  effectively  used.  The  enclometrium  is  swabbed  with  nitric  acid 
(C.  P.)  or  with  the  perchloride  of  iron. 

Surgical  Treatment. — Whatever  may  be  the  underlying  cause 
of  uterine  hemorrhage  the  curet  is  the  common  resort  with  the  pro- 
fession in  general.  The  curet  is  capable  of  much  harm  and  should 
not  be  used  by  the  ignorant  or  the  careless.  The  subject  is  fully  dis- 
cussed on  page  126,  where  its  limitations  are  defined. 

For  the  treatment  of  uterine  hemorrhage  dependent  upon  displace- 
ments of  the  uterus,  metritis,  subinvolution,  pelvic  inflammation, 
cystic  ovaries,  extra-uterine  pregnancy,  incomplete  abortion,  fibroids, 
cancer,  sarcoma,  syncj'tioma  malignum,  muscular  insufficiency,  arterio- 
sclerosis, and  other  morbid  states,  the  existing  morbid  conditions  must 
be  corrected  or  removed.  These  subjects  will  be  discussed  under 
their  respective  heads. 

When  the  patient  has  lost  blood  to  the  extent  of  creating  so  grave 
an  anemia  as  to  render  an  operation  under  anesthesia  hazardous,  it 
is  well  to  control  the  hemorrhage  by  tentative  measures  until  the  blood 
is  sufficiently  restored  to  justifiy  operative  interference.  To  this  end 
rest  in  bed  should  be  enjoined,  a  light  but  nourishing  diet  should  be 
given,  blood  tonics  administered,  the  uterus  curetted,  and  the  vagina 
packed  with  gauze.  The  author  has  repeatedly  succeeded  in  improving 
the  blood  at  the  rate  of  1  per  cent,  a  day  under  this  treatment,  and  thus 
speedily  brought  the  patient  to  a  safe  condition  for  operation.  Below 
40  per  cent,  of  hemoglobin,  2,000,000  red  corpuscles,  and  a  blood 
pressure  of  100,  it  is  not  safe  to  perform  a  major  operation.  Nothing 
short  of  an  emergency  would  justify  surgical  interference  when  the 
blood  findings  are  below  this  point. 


CHAPTER  II 

DISORDERS  ASSOCIATED  WITH  MENSTRUATION- 
BACKACHE— ENTEROPTOSIS 


DISORDERS   ASSOCIATED  WITH  MENSTRUATION 


Amenorrhea 

Physiological    Absence    of    Men- 
struation 
General  Causes 
Local  Causes 
Menstrual  Molimina 
Vicarious  Menstruation 
Diagnosis 
Treatment 


Pain  in  Pelvis  during  Menstrua- 
tion (Dysmenorrhea) 

Primary 

Secondary 

Membranous  Dysmenorrhea 

Nasal  Dysmenorrhea 

Periodic    Intermenstrual    Pain 
(Mittelschmertz) 

Treatment 

Dysmenorrhea  Due  to  a  Conical 
Cervix 


Amenorrhea. — Physiological  Absence  of  Menstruation. — In  determining 
the  causes  of  amenorrhea  it  is  well  to  bear  in  mind  the  physiological 
conditions  in  which  the  menses  fail  to  appear. 

1.  Before  puberty. 

2.  During  irregular  intervals  at  the  time  of  the  establishment  of 
menstruation. 

3.  During  pregnancy  and  a  variable  time  in  the  period  of  lactation. 

4.  During  the  establishment  of  the  climacterium — "dodging  period." 

5.  After  the  menopause. 

When  the  menstrual  flow  is  retarded  or  when  the  quantity  is  less 
than  normal  the  condition  is  known  as  amenorrhea.  The  term  may 
be  further  qualified  by  the  words  relative  and  absolute. 

By  relative  amenorrhea  is  meant  a  menstrual  flow  that  is  below  the 
normal  amount  for  the  given  individual.  What  is  abnormal  for  one 
may  be  normal  for  another,  depending  upon  the  general  condition  of 
the  individual. 

By  absolute  amenorrhea  is  meant  a  total  suppression  of  the  menses. 

The  causes  of  amenorrhea  are  both  general  and  local. 

General  Causes. —  Debilitating  diseases,  such  as  primary  anemia, 
diabetes,  Bright's  disease,  tuberculosis,  malaria,  and  nervous  dis- 
eases, are  contributing  factors.  Chlorosis  is  probably  the  most  common 
cause  of  amenorrhea  in  girls.  In  determining  the  cause  of  amenorrhea 
it  is  not  enough  to  establish  the  fact  of  anemia,  but  the  character  of 
the  anemia  must  be  ascertained  by  an  analysis  of  the  blood,  and,  if 
possible,  the  underlying  cause  must  be  demonstrated. 

The  secondary  anemias  are  grouped  according  to  general  causes  into 


38  DISORDERS  ASSOCIATED  WITH  MENSTRUATION 

those  due  to  deficient  nutrition  and  those  due  to  increased  waste. 
Digestive  and  respiratory  disorders  Hmit  the  supply  of  blood  and 
oxygen  essential  to  the  proper  nourishment  of  the  body,  and,  indirectly, 
to  the  performance  of  the  menstrual  functions. 

Amenorrhea  is  not  infrequently  the  first  suggestion  of  the  presence 
of  an  incipient  tuberculosis.  Formerly  these  cases  were  commonly 
regarded  as  chlorotic,  inasmuch  as  the  two  affections  present  the 
same  blood  findings.  Furthermore  the  same  treatment,  fresh  air  and 
abundant  diet,  with  regulation  of  the  bowels,  is  employed  for  both.  It 
is  encouraging  to  note  that  tuberculosis  presents  the  more  favorable 
prognosis,  since  genuine  chlorosis  is  likely  to  be  associated  with  defects 
in  the  bloodmaking  organs,  or  with  an  abnormally  small  size  of  the 
heart  and  bloodvessels;  conditions  which  cannot  be  remedied. 

Change  in  environment  conduces  to  constipation,  and  it  is  observed 
that  by  regulating  the  bowels  these  amenorrheics  are  more  readily 
benefited  than  by  any  other  process. 

Hemorrhage  from  any  part  of  the  body,  chronic  diarrhea,  continued 
suppuration,  albuminuria,  and  the  like,  result  in  excessive  waste  that 
will  bring  about  amenorrhea. 

Changes  in  Environmeiit. — These  are  often  followed  by  amenorrhea 
for  a  variable  length  of  time.  Girls  coming  from  foreign  countries  to 
the  United  States  commonly  experience  a  delay  in  the  appearance  of 
the  menses  for  a  variable  time. 

Mental  Shock  and  Anxiety. — These  may  cause  a  suppression  of  the 
menses.  The  fear  of  conception  may  suppress  the  menstrual  periods, 
and  when  the  fears  are  allayed  the  menses  may  promptly  return. 

"Catching  Cold." — This  is  a  term  in  ordinary  usage,  implying  a 
congestion  of  the  pelvic  ^'iscera.  Part  or  all  of  the  menses  may  be 
suppressed  by  exposure  to  cold  immediately  before  and  during  the 
menstrual  period. 

Acute  Infectious  Diseases.  —  Acute  infectious  diseases,  including 
diphtheria,  pneumonia,  scarlet  fever,  and  acute  articular  rheumatism, 
may  be  followed  by  a  period  of  amenorrhea,  and  may  result  in  perma- 
nent suppression  of  the  menses  through  degenerative  changes  in  the 
uterus  and  ovaries. 

Nervous  Diseases. — Nervous  diseases,  including  melancholia,  various 
forms  of  insanity,  and  imbecility,  are  not  infrequently  responsible  for 
amenorrhea.  In  many  instances  the  amenorrhea  is  thought  to  be  the 
exciting  cause  of  the  nervous  disorders. 

Drug  Addictions. — Morphinism  is  an  occasional  cause  of  amenorrhea. 
The  same  is  said  of  alcoholism  and  lead  poisoning. 

Temporary  Amenorrhea. — Temporary  amenorrhea  is  not  uncommon 
in  young  women  as  a  result  of  worry  and  anxiety,  change  of  residence, 
and  mode  of  life.  In  every  instance  the  possibility  of  pregnancy  must 
be  borne  in  mind,  and  when  it  cannot  be  positively  excluded,  the  patient 
must  be  kept  under  observation  until  such  time  as  positive  signs  of 
pregnancy  would  be  manifest. 

Following  typhoid  fever,  diphtheria,  scarlet  fever,  and  other  acute 


AMENORRHEA  39 

infections  the  menses  may  not  return  for  several  months.  Amenorrhea 
is  an  early  accompaniment  of  pulmonary  tuberculosis,  a  fact  which 
has  led  to  the  impression  among  the  laity  that  amenorrhea  causes 
tuberculosis. 

Disordered  Functions  of  the  Ductless  Glands. — These  constitute  im- 
portant factors  in  the  development  of  amenorrhea,  though  as  yet  the 
problems  connected  with  this  subject  are  largely  theoretical.  When 
there  is  a  lack  of  thyroid  substance  in  the  system,  as  occurs  in  m^'x- 
edema,  amenorrhea  is  usually  a  symptom.  In  exophthalmic  goitre 
relative  amenorrhea  is  sometimes  observed,  though  as  a  rule  the 
menstrual  flow  is  increased.  The  first  symptom  of  Addison's  disease 
is  likely  to  be  amenorrhea.  In  acromegaly,  when  the  pituitary  body 
is  atrophied,  amenorrhea  is  usually  present  as  one  of  the  earliest 
symptoms.     Cretinism  is  commonly  associated  with  amenorrhea. 

Local  Causes. — Congenital  Absence  of  Organs. — Congenital  absence  of 
the  organs  essential  to  menstruation,  namely,  the  uterus  and  ovaries,  is 
a  rare  causal  factor. 

Hypoplasia  and  Atrophy. — Hypoplasia  and  atrophy  of  the  organs 
essential  to  menstruation,  are  often  accompanied  by  chlorosis.  Here 
the  ovaries  are  primarily  affected. 

Atresia. — Retention  of  the  menses  occurs  from  atresia  of  the  cervix 
and  vagina,  imperforate  hymen,  and  tumor  formations  obstructing  the 
outflow  of  the  menstrual  blood.     (See  Chapter  XY.) 

Atresic  conditions  of  the  vulva,  vagina,  and  cervix  are  congenital 
in  about  one-third  and  acquired  in  about  two-thirds  of  the  cases.  The 
acquired  forms  are  the  result  of  gonorrheal  vulvo-vaginitis  and  the 
sequelae  of  infectious  diseases. 

Puerperal  ulcers  of  the  vagina  and  vulva  may  lead  to  atresia,  as  may 
also  extensive  lacerations  following  labor.  Ill-fitting  pessaries  worn 
over  a  long  period  are  occasional  factors.  Application  of  caustics  to 
the  cervix  and  endometrium  may  induce  amenorrhea  through  atresia. 

Removal  of  Uterus  and  Ovaries. — Removal  of  the  uterus  or  ovaries, 
doing  away  with  the  menstrual  flow. 

Diseases  of  Genital  Organs. — Diseases  of  the  genital  organs  which 
disable  and  destroy  the  tissues  essential  to  menstruation — i.  e.,  metritis, 
endometritis,  cystic  degeneration  of  the  ovaries  and  new-formations 
in  the  uterus  and  ovaries — are  occasional  causes  of  amenorrhea. 

Adipostity  Associated  with  Anemia. — The  fault  may  rest  primarily 
in  the  ovaries. 

Amenorrhea  without  Apparent  Cause. — ^The  general  and  local  condi- 
tions of  an  individual  may  appear  perfectly  normal  in  the  presence  of 
amenorrhea. 

Effects  of  Ovariotomy  ox  Mexstruatiox. — In  this  relation  it  is 
interesting  to  note  the  eft'ect  of  the  removal  of  the  ovaries  upon  men- 
struation. After  both  ovaries  are  removed,  menstruation  stops  abruptly 
in  66  per  cent,  of  cases.  In  the  remaining  33  per  cent.,  menstruation 
stops  gradually  throughout  a  period  of  one  to  six  months. 

The  cause  of  uninterrupted  menstruation  after  double  ovariotomy 


40  DISORDERS  ASSOCIATED  WITH  MENSTRUATION 

is  explained  by  the  presence  of  a  supernumerary  ovary  or  by  the 
accidental  leaving  of  a  bit  of  ovarian  tissue  adherent  to  the  neighboring 
structures.  A  small  portion  of  the  ovary  may  have  been  constricted 
off  from  the  parent  ovary  by  contracting  bands  of  adhesions,  and  may 
escape  notice  in  the  removal  of  the  ovary.  The  law  of  persistence  of 
habit  may  explain  an  occasional  case.  More  often  a  flow  persists  as 
the  residt  of  a  uterine  tumor  or  an  inflammatory  lesion,  and  is  not, 
strictly  speaking,  a  menstrual  flow. 

Menstrual  Molimina. — The  local  and  general  disturbances  which  accom- 
pany the  menstrual  flow  ?ire  designated  as  the  menstrual  molimina. 
These  disturbances  are  pain  in  the  region  of  the  ovaries,  in  the  back, 
and  radiating  to  the  thighs;  also  flushing  of  the  face,  dizziness,  palpi- 
tation, and  headache.  The  duration  of  these  symptoms  varies  from 
a  few  hours  to  the  entire  month.  The  menstrual  molimina  generally 
begin  about  one  month  after  the  removal  of  the  ovaries,  and  extend 
over  a  period  of  one  or  two  years,  sometimes  much  longer. 

When  the  uterus  alone  is  underdeveloped  and  the  ovaries  are 
sufficiently  developed  to  functionate,  there  will  be  little  or  no  flow  of 
blood,  but  the  other  phenomena  of  menstruation  which  mark  the  con- 
dition known  as  the  menstrual  molimina  appear  at  monthly  intervals. 

Vicarious  Menstruation. — Vicarious  menstruation  is  a  discharge  of  blood 
at  the  menstrual  period  from  some  part  of  the  body  other  than  the  uterus. 
These  hemorrhages  may  occur  simultaneously  with  the  uterine  menstrual 
flow,  or  in  the  absence  of  all  bleeding  from  the  uterus.  Almost  all 
mucous  and  cutaneous  surfaces  have  been  known  to  menstruate 
vicariously,  notably  the  nose,  stomach,  intestines,  and  bronchi.  The 
urethra,  bladder,  throat,  conjunctiva,  and  ears  bleed  less  frequently. 
Instead  of  blood,  other  discharges  ma}^  take  place.  Cases  have  been 
recorded  of  periodical  diarrhea,  leucorrhea,  and  secretions  of  milk  from 
the  breast.  Ulcers  and  cicatrices  have  been  known  to  bleed  at  the  men- 
strual period.  A  nevus  on  the  face  has  been  known  to  bleed  simultane- 
ously with  the  menstrual  flow.  The  cervix  was  observed  to  menstruate 
by  Ashton  after  the  removal  of  the  body  of  the  uterus  and  ovaries. 

Diagnosis. — The  diagnosis  of  amenorrhea  is  made  solely  upon  estab- 
lishing the  fact  of  the  non-appearance  of  the  menstrual  flow.  Such  a 
diagnosis  is  of  little  value  unless  the  cause  of  the  amenorrhea  is  clearly 
established.  Pregnancy  must  always  be  excluded  before  considering 
other  possible  causes,  and  in  doing  so  it  is  often  necessary  to  observe 
the  patient  for  a  limited  period. 

When  a  patient  presents  herself  complaining  of  amenorrhea,  her 
age  will  suggest  the  possible  cause.  If  she  is  about  the  age  of 
puberty,  the  irregularities  which  commonly  mark  the  establishment  of 
the  menstrual  function  suggest  themselves;  if  in  the  period  of  sexual 
maturity,  the  possibility  of  pregnancy  is  uppermost  in  the  mind;  and 
if  at  a  later  period,  the  menopause  is  suggested.  Again,  if  the  patient 
has  never  menstruated  and  has  advanced  beyond  the  age  of  puberty  a 
defect  in  the  development  of  the  sexual  organs  is  naturally  suggested. 

So  varied  are  the  causes  of  amenorrhea  that  without  a  searching 


AMENORRHEA  41 

physical  examination  the  diagnosis  of  the  cause  cannot  be  known, 
and  without  a  diagnosis  the  treatment  cannot  be  wisely  directed, 
inasmuch  as  amenorrhea  is  but  a  symptom,  and  rational  treatment  is 
based  upon  the  removal  of  the  cause. 

First  of  all  the  question  must  be  determined  as  to  whether  the 
amenorrhea  under  consideration  is  physiological.  The  questions  asked 
are:  Is  it  time  for  the  establishment  of  puberty?  Is  it  possible  for 
pregnancy  to  exist?'  Is  the  patient  nursing  a  child?  Is  she  in  the 
dodging  period  of  life?    Has  she  reached  the  menopause? 

All  of  these  questions  must  be  settled  before  it  is  possible  to  pass 
to  a  consideration  of  the  many  general  and  local  conditions  which 
may  have  a  direct  bearing  upon  the  existing  amenorrhea. 

Having  answered  them  in  the  negative  a  consideration  of  the  systemic 
causes  of  amenorrhea  is  taken  up.  Is  the  patient  suffering  from  or  has 
she  recently  suffered  from  a  debilitating  disease,  such  as  tuberculosis, 
malaria,  nephritis,  anemia,  and  digestive  disorders  ?  If  so,  the  cause 
of  the  amenorrhea  may  be  thus  explained  and  a  rational  course  of 
general  treatment  is  suggested. 

Treatment. — The  habits  of  the  individual  should  be  investigated  in 
reference  to  her  mode  of  living  and  possible  dissipations.  If  she  has 
recently  changed  her  residence  to  another  climate  or  to  some  foreign 
country,  the  assumption  is  not  out  of  place  that  in  due  time  the  men- 
strual periods  will  be  reestablished.  If  she  is  addicted  to  the  morphine 
habit,  its  correction  may  bring  relief.  If  she  has  suffered  from  some 
mental  shock  or  anxiety  or  from  some  nervous  disorder,  the  treatment 
is  best  directed  toward  the  relief  of  these  conditions. 

There  is  a  so-called  functional  amenorrhea  in  which  the  genital 
organs  are  apparently  healthy  and  the  general  state  of  health  is  good. 
Such  cases  call  for  no  active  treatment,  either  local  or  general.  The 
thought  of  these  patients  should  be  directed  away  from  their  sexual 
disorders,  daily  exercise  in  the  open  air  should  be  insisted  upon,  and 
the  excretions  and  diet  properly  regulated.  Local  treatments  are 
meddlesome  and  cannot  be  productive  of  good. 

The  chlorosis  of  young  women,  which  is  commonly  associated  with 
amenorrhea,  is  best  treated  by  a  judicious  regulation  of  exercise  in 
the  open  air,  by  prescribing  a  liberal  diet,  and  by  the  administration 
of  iron  and  arsenic.  Too  constant  application  to  study  should  be 
discouraged;  shorter  hours  in  school  and  longer  hours  of  rest  and 
exercise  in  the  open  air  are  imperative.  In  severe  cases  it  may  be 
necessary  to  take  the  girl  out  of  school  for  a  time.  Blaud's  pill  in  1-  to 
2-grain  doses,  together  with  3  to  7  drops  of  Fowler's  solution  given 
after  each  meal  and  at  bedtime  and  continued  several  months,  will 
often  effect  relief.  ^Vhen  iron  is  not  well  borne  by  the  mouth  it 
may  be  given  hypodermically  in  the  form  of  ammonio-citrate  of  iron, 
I  grain  dissolved  in  ^  dram  of  sterile  water.  Laxatives  are  essential 
in  regulating  the  bowels. 

1  to  5  grains  of  reduced  iron  in  pill  form  is  a  favorite  method  of 
administering  iron  in  chlorosis. 


42  DISORDERS  ASSOCIATED  WITH  MENSTRUATION 

Acting  on  the  theory  that  chlorosis  is  due  to  the  lack  of  internal 
secretion  of  the  ovary  it  would  be  logical  to  administer  corpus  luteum 
extract  (Parke,  Davis  &  Co.),  given  in  capsules  of  5  grains  each  after 
meals  and  at  bedtime.  Bandler  recommends  ovariin  for  the  same 
purpose. 

Emmenagogues  designed  to  stimulate  the  menstrual  flow  cannot 
be  depended  upon  and  are  not  recommended. 

There  is  no  surgery  for  amenorrhea  unless  the  obstruction  to  the  out- 
flow of  the  menstrual  blood  is  regarded  as  an  example  of  amenorrhea. 

The  following  prescriptions  are  recommended  by  the  author: 

I^ — Magnesii  dioxid 3j  4 1 

Aloin gr-  iij  1 194 

Fiat.  pil.  no.  xxx. 

Sig. — One  pill  three  times  daily. 

I^ — Strychninse  nitratis gr-  iij  1 194 

Apioline 3j  4| 

Fiat.  caps.  no.  xxiv. 

Sig. — One  capsule  after  meals. 

Pain  in  the  Pelvis  during  Menstruation  (Dysmenorrhea). — Pain 
in  the  pelvis  is  often  referred  to  the  uterus  or  ovaries.  Of  all  pains  in 
the  abdomen  the  so-called  "ovarian  pain"  is  by  far  the  most  usual. 
Experience  has  taught  that  pain  is  referred  to  the  ovary  of  the  left 
side  three  times  as  frequently  as  to  the  right.  There  is  no  satisfactory 
explanation  for  this.  It  is  a  matter  of  every-day  clinical  experience 
that  the  pain  is  often  referred  to  the  left  ovary  when  there  is  no 
apparent  disease  in  either  ovary;  more  than  that,  there  may  be 
no  demonstrable  lesion  in  the  pelvis.  Even  more  strange  is  the 
finding  of  the  lesion  in  the  right  ovary  and  the  pain  referred  to  the  left 
ovary.  The  author  makes  no  attempt  to  explain  these  facts.  Certain  it 
is  that  reflex  pains  may  be  located  in  the  ovary  and  the  lesion  confined 
to  the  uterus  or  opposite  ovary.  It  must  not  be  inferred  from  com- 
plaints of  pain  in  the  ovary  that  its  structure  is  diseased,  but  such 
pains  may  well  suggest  possible  lesions  in  one  or  more  of  the  pelvic 
viscera.  Such  pains  are  particularly  frequent  and  severe  at  the  time 
of  the  menstrual  period.  This  leads  to  the  discussion  of  dysmenorrhea, 
a  term  often  misused  and  little  understood. 

Ernest  Herman  estimates  that  only  40  per  cent,  of  women  menstruate 
without  pain,  and  that  10  to  20  per  cent,  of  unmarried  women  are 
bedridden  with  pain  during  a  part  or  all  of  the  menstrual  period. 

Primary  Dysmenorrhea. — In  determining  the  cause  of  dysmenorrhea 
the  condition  of  the  nervous  system  must  first  be  considered.  A  con- 
dition causing  pain  in  one  individual  may  be  unnoticed  in  another  of 
more  stable  equilibrium.  When  pain  in  the  pelvis  is  complained  of 
during  and  between  the  menstrual  periods  and  a  thorough  examination 
reveals  nothing  abnormal  in  the  pelvis,  it  is  a  common  habit  to  conclude 
that  the  fault  lies  in  a  functional  derangement  of  the  nervous  system, 
and  such  vague  terms  as  hysteria,  neurasthenia,  and  neuroses  are 
applied.     A  certain  degree  of  pain  during  the  menstrual  period  may 


DYSMEXORRHEA  43 

be  considered  within  normal  limits,  and  in  very  nervous  women  such 
pains  may  become  exaggerated  to  actual  suffering. 

The  author's  opinion  is  that  severe  dysmenorrhea  in  the  absence  of 
pelvic  abnormalities  is  rare.  The  individual  becomes  more  and  more 
nervous  as  the  result  of  her  periodic  suffering.  The  author,  therefore, 
is  inclined  to  regard  the  general  nervousness  as  an  effect  rather  than  a 
cause  of  the  menstrual  pain.  The  local  disorder  may  be  nothing  more 
than  a  tetanic  contraction  of  the  sphincter  uteri,  which  does  not  occur 
in  the  intermenstrual  period.  Such  cases  respond  to  dilatation  of  the 
cervix.     They  are  also  the  cases  which  are  relieved  by  childbearing. 

The  explanation  of  the  "normal"  menstrual  pain  is  probably  found 
in  the  engorgement  of  the  endometrium,  which,  acting  as  a  foreign 
body,  excites  the  uterus  to  contract;  and  it  is  these  uterine  contractions 
which  occasion  the  pain.  In  many  of  the  pathological  lesions  involving 
the  pelvic  viscera,  the  menstrual  congestion  is  added  to  the  already 
engorged  tissues,  and  the  pain  is  severe.  It  is  exceptional  for  patho- 
logical lesions  to  exist  in  the  uterus  and  adnexa  without  dysmenorrhea, 
but  knowing  such  to  be  possible,  and,  on  the  other  hand,  knowing 
that  pain  of  equal  intensity  may  exist  in  the  absence  of  a  pathological 
lesion,  it  is  difficult  to  determine  how  much  of  the  pain  is  due  to  struc- 
tural changes  and  how  much  to  an -excitable  nervous  system.  Thus 
dysmenorrhea  is  spoken  of  as  being  idiopathic  or  primary  when  it  is 
evident  that  the  pain  bears  no  relation  to  pathological  lesions  of  the 
genitalia,  and  secondary  when  it  is  evident  that  the  pain  is  the  direct 
result  of  a  morbid  condition  in  the  genital  tract. 

Schultze  suggested  an  explanation  for  dysmenorrhea  occurring  in 
young  girls  and  young  women  in  whom  nothing  abnormal  was  dis- 
covered to  account  for  the  pain.  He  suggests  the  possibility  of  hypo- 
plasia of  the  uterine  musculature  being  present,  and  hence  the  uterus 
is  unable  to  expel  the  menstrual  blood  as  fast  as  it  accumulates  in 
the  uterus.  In  this  condition  two  sorts  of  pain  may  arise,  premenstrual 
and  menstrual,  the  former  being  due  to  tension  in  the  congested  uterus. 
In  these  cases  pregnancy  often  results  in  a  cure  because  of  the  develop- 
ment of  the  uterine  musculature. 

Secondary  Dysmenorrhea. — Secondary  dysmenorrhea  may  be  caused 
by  all  lesions  of  the  genital  tract.     These  may  be  classified  under: 

MalderelopmenU  and  Malformations. — INIaldevelopments  and  mal- 
formations, which  cause  menstrual  pain  by  obstructing  the  outflow 
of  the  menstrual  blood.  In  this  category  may  be  included  absence  or 
atresia  of  the  vulva,  vagina,  and  cervix.  The  menstrual  molimina  are 
experienced,  but  without  a  show  of  blood.  With  the  return  of  each 
monthly  period  the  pain  increases  in  intensity  as  the  result  of  accu- 
mulated blood  within  the  vagina,  uterus,  tubes,  and,  possibly,  the  pelvis. 
The  obstruction  may  not  be  complete,  and  the  retarded  blood,  having 
time  to  coagulate,  is  then  expelled  with  cramp-like  pains — the  so-called 
"obstructive  dysmenorrhea." 

Superinvolution  of  the  uterus  is  associated  with  painful  menstruation, 
the  cause  of  which  is  not  understood.     A  congenitally  small  uterus 


44 


DISORDERS  ASSOCIATED  WITH  MENSTRUATION 


(infantile)  is  likewise  associated  with  dysmenorrhea.  In  either  case 
the  explanation  possibly  lies  in  the  encroachment  of  the  tissue  fibers 
upon  the  nerve  filaments  of  the  uterus. 

Malpositions. — Malpositions  of  the  uterus  and  adnexa  are  less  fre- 
quently the  cause  of  dysmenorrhea  than  are  the  associated  lesions.  It 
is  exceptional  for  the  menstrual  blood  to  be  obstructed  in  its  outflow 
by  the  bending  or  twisting  of  the  long  axis  of  the  uterus.  Pain  is  more 
often  the  result  of  complicating  lesions  in  and  about  the  uterus  and 
its  appendages. 


Fig.  1 


Showing  uterine  pain  referred  to  the  suprapubic  region  and  to  the  breast. 


Anteflexion  of  the  uterus,  when  extreme,  is  almost  always  associated 
with  pain.  The  cause  of  the  pain  in  these  cases  is  still  a  matter  of 
controversy.  It  is  not  probable  that  the  canal  is  obstructed  by  the 
bending  of  the  uterus,  as  was  formerly  believed.  Hyperesthesia, 
resulting  in  muscular  spasms  of  the  internal  os,  is  a  more  satisfactory 
explanation  for  the  obstruction.  It  is  evident  that  the  pain  in  such 
cases  is  largely  neurotic  in  origin. 

Anteflexion  of  the  uterus  is  said  to  be  a  frequent  cause  of  dysmen- 
orrhea in  virgins  and  nulliparous  married  women.  In  these  cases  it 
is  often  observed  that  a  small  sound  will  pass  the  internal  os,  yet  there 
is  evident  mechanical  obstruction  to  the  outflow  of  the  menstrual 
blood.  The  explanation  lies  in  the  swelling  of  the  mucous  membrane 
during  the  menstrual  period,  together  with  spasm  of  the  sphincter 
above  referred  to.    The  passing  sound  compresses  the  swollen  mucosa. 


DYSMENORRHEA 


45 


Inflamvmtory  Diseases. — In  inflammatory  diseases  of  the  uterus 
and  adnexfe,  which  are  more  or  less  tender  and  painful  in  the  inter- 
menstrual period,  the  suffering,  is  greatly  intensified  by  the  menstrual 
flux — -"congestive  dysmenorrhea."  Plugs  of  tenacious  mucus  may  fill 
the  cervical  canal  and  obstruct  the  menstrual  flow. 

New-formations. — Xew-formations,  notably  fibroid  tumors  in  the 
genital  tract,  may  obstruct  the  menstrual  blood — "  obstructive  dysmen- 
orrhea." Pelvic  tumors  share  in  the  menstrual  congestion,  and  by  their 
enlargement  the  pressure  sjTnptoms  are  intensified. 

Fig.  2 


Location  of  pain  referred  to  the  uterus. 


Membranous  Dysmenorrhea. — ^Membranous  dysmenorrhea  is  a  term 
first  applied  by  ]vIorgagni.  In  this  condition  there  is  a  discharge  at 
the  menstrual  period  of  a  part  or  of  the  whole  of  a  cast  of  the  uterine 
cavity.  The  discharge  of  the  membrane  may  occur  but  once  or  at  suc- 
cessive menstrual  periods.  If  it  were  believed  that  the  endometrium  is 
shed  at  each  menstrual  period,  the  conclusion  might  readily  be  accepted 
that  membranous  dysmenorrhea  is  merely  an  exaggeration  of  the 
normal  process.  The  membrane  may  be  shed  as  a  complete  triangular 
cast  of  the  uterus,  or  may  be  discharged  in  shreds. 

Membranes  are  more  frequently  passed  in  the  menstrual  flow  than 
is  knowm.     ^Yithout  a  svstematic  examination  of  the  clots  expelled. 


46 


DISORDERS  ASSOCIATED  WITH  MENSTRUATION 


such  membranes  will  often  escape  notice.  Sir  I.  Williams  found  mem- 
branes in  three-fourths  of  his  cases  of  dysmenorrhea  and  Scanzoni 
in  two-thirds.  They  may  be  passed  without  pain.  The  possibility 
of  monthly  abortions  must  be  borne  in  mind.  Virgins  and  sterile 
women  are  most  affected,  though  the  disease  is  not  unknown  to  women 
who  have  borne  children.  The  diagnosis  depends  upon  a  careful 
examination  of  the  expelled  membrane.    (See  Chapter  VIII.) 

Fig.  3 


Showing  location  of  ovarian  pain  referred  to  the  breast,  to  the  iliac  region,  and  to  the  inner  aspect 

of  the  thigh. 


Under  the  microscope  a  great  variation  in  structure  is  seen.  The 
membrane  may  resemble  an  hypertrophied  endometrium,  a  decidua, 
or  a  fibrinous  membrane.  Accompanying  the  discharge  of  the  mem- 
brane is  intense  pain.  The  membrane  is  not  to  be  mistaken  for  the 
decidua  of  extra-uterine  or  intra-uterine  pregnancy. 

Nasal  Dysmenorrhea.^ — Fliess,  in  1897,  demonstrated  a  definite  rela- 
tionship between  the  mucous  membrane  of  the  nose  and  the  genitalia 
in  women.  He  observed  certain  swollen  and  tender  red  spots  ("genital 
spots")  on  the  nasal  septum  and  inferior  turbinates.  Schiff  made  a 
number  of  clinical  observations  and  conclusively  demonstrated  that 
temporary  relief  is  often  afforded  by  cocainizing  these  genital  spots, 
and  that  permanent  relief  can  be  afforded  by  the  use  of  the  cautery. 
Ephraim  treated  twenty-four  cases  with  eight  good  results.  These 
reflexes,  together  with  the  established  fact  of  vicarious  menstruation 


DYSMENORRHEA 


47 


from  the  nose,  would  appear  to  establish  beyond  a  doubt  an  intimate 
relationship  between  the  nasal  and  genital  passages.  In  these  cases 
great  caution  was  exercised  in  excluding  the  influence  of  mental  sug- 
gestion. The  author  is  inclined  to  believe  that  the  procedure  is 
irrational  and  will  not  stand  the  test  of  time. 


Fig.  4 


Location  of  pain  referred  to  the  tubes  and  ovaries. 

Periodic  Intermenstrual  Pain  (Mittelschmertz) .— B y  the  term  inter- 
menstrual pain,  a  condition  is  understood  in  which  pain  of  a  definite 
character  recurs  at  monthly  intervals  between  the  regular  menstrual 
periods.  Very  often  the  time  is  midway  between  menstrual  periods, 
but  may  be  earlier  or  later. 

Time  of  Occurrence. — These  intermenstrual  pains  may  begin  with 
the  establishment  of  the  menstrual  cycle,  but  in  the  majority  of  cases 
they  first  appear  some  years  after  puberty.  They  may  persist  through- 
out the  entire  menstrual  life  or  may  recur  at  regular  intervals  over  a 
much  shorter  period. 

Childbearing  in  relation  to  intermenstrual  pain  is  of  significant 
interest.     In  an  excellent  article  Heaney^  analyzed  the  reports  of  66 


1  Surg.,  Gyn.,  and  Obst.,  October,  1910. 


48  DISORDERS  ASSOCIATED  WITH  MENSTRUATION 

cases,  showing  that  the  affection  occurs  with  greatest  frequency  at  the 
period  of  sexual  maturity.  There  was  a  high  percentage  of  steriHty; 
only  3  of  the  66  became  pregnant  after  the  onset  of  intermenstrual 
pain  and  but  one  of  these  carried  the  child  to  term.  In  the  majority  of 
cases  the  intermenstrual  pain  began  one  or  more  years  after  puberty. 

Heaney  says,  "Pain  is  the  fixed  symptom  and  is  very  character- 
istic." The  pain  appears  in  the  intermenstrual  period  with  the  same 
regularity  as  the  menstrual  periods.  These  pains  are  colicky  in  type 
and  are  more  common  on  the  left  side  of  the  pelvis.  In  more  severe 
cases  the  pain  is  referred  to  the  entire  pelvic  region  and  may  radiate 
to  one  or  both  thighs. 

Leucorrhea. — While  there  is  an  accompanying  vaginal  discharge  in 
many  of  these  cases,  it  is  not  possible  to  establish  any  direct  or  indirect 
relationship  between  the  vaginal  discharge  and  the  pain. 

Dysmenorrhea. — There  is  no  direct  relationship  established  between 
intermenstrual  and  menstrual  pains.  In  about  half  the  cases  there  are 
no  menstrual  pains.  » 

Associated  Pathological  Lesions.— In  a  small  proportion  of  cases 
the  pelvic  organs  appear  perfectly  normal,  while  in  many  cases  the 
lesions  found  cannot  be  held  responsible  for  the  pain.  There  is  a 
preponderance  of  uterine  fibroids  in  these  cases.  The  belief  is  fre- 
quently expressed  that  the  tube  is  the  seat  of  the  pain.  Giles  and 
Bland  Sutton  believed  the  symptom  complex  to  be  due  to  intermittent 
hydrosalpinx,  the  pain  being  due  to  the  effort  of  the  tube  in  expelling 
the  contained  fluid.  Observations  after  operation  do  not  support 
this  theory.  Heaney  believes  that  "  Mittelschmertz"  is  an  abortive 
attempt  at  menstruation,  having  as  its  foundation  sclerosed  ovaries 
and  uterus. 

Treatment. — The  disease,  if  it  may  be  called  a  disease,  is  not  self- 
limited.  Numerous  methods  of  treatment,  both  general  and  local, 
have  been  suggested,  and  with  indifferent  results.  Ovarian  extract, 
thyroid  extract,  electricity,  stem  pessary,  dilatation  and  curettage, 
removal  of  one  or  both  appendages,  all  these  have  been  tried  with  but 
an  occasional  good  result. 

All  that  can  be  said  is  that  the  general  condition  of  the  patient 
should  be  improved  by  hygienic  measures,  notably  rest,  outdoor 
exercise,  nourishing  diet  and  baths,  and  finally,  that  lesions  within 
the  pelvis  which  may  possibly  account  for  pain  should  be  removed. 
The  most  plausible  explanation  for  the  pain  is  that  of  Priestly,  who 
believes  the  pain  to  be  dependent  upon  ovulation.  It  is  known  that 
ovulation  occurs  in  the  intermenstrual  period,  and  usually  midway 
between  periods,  hence  the  suggestion  that  nothing  short  of  removal 
of  the  ovary  will  effect  a  cure  with  any  degree  of  certainty.  '  Resort 
to  this  procedure  should  be  taken  with  great  deliberation,  if  indeed  it 
should  be  countenanced. 

Treatment  of  Dysmenorrhea. — Of  all  the  sj-mptoms  complained  of  by 
women,  pain  is  the  least  trustworthy,  inasmuch  as  pain  may  be  present 
without  any  demonstrable  lesion,  and,  on  the  other  hand,  pain  may  be 


DYSMENORRHEA  49 

absent  in  the  presence  of  any  of  the  pelvic  lesions.  The  psychic  element 
plays  a  most  important  role,  and  must  always  be  reckoned  with  in 
estimating  the  significance  of  pain. 

Medical  Treatment. — ^A  very  large  proportion  of  women  suffering 
from  dysmenorrhea  are  psychoneurotics,  hence  the  great  value  of 
psychic  and  hygienic  treatment.  In  the  absence  of  demonstrable 
pelvic  lesions  the  management  of  this  class  of  cases  is  in  general  as 
follows : 

Open-air  exercise  regulated  in  accordance  with  the  patient's  strength 
and  the  placing  of  the  patient  under  conditions  that  will  most  agreeably 
absorb  her  attention  and  take  her  mind  from  her  fancied  ailments; 
the  stimulating  cold  plunge  or  shower  in  the  morning  and  the  sedative 
hot  bath  in  the  evening,  and  finally  the  enjoining  of  rest  in  bed  for 
two  or  three  days  at  the  onset  of  menstruation;  all  these  provisions 
will  tend  to  lead  her  out  of  her  troubles  and  effect  a  cure. 

It  is  most  important  to  look  to  the  general  nutrition.  Many  of 
these  patients  are  underfed,  and  it  will  be  found  that  they  become 
more  tolerant  to  suffering  and  indeed  suffer  less,  as  they  become  better 
nourished.  They  should  be  instructed  to  take  a  liberal  mixed  diet 
at  the  regular  meal  hours  and  between  meals,  and  at  bedtime  should 
be  given  a  glass  of  milk,  malted  milk,  cocoa,  or  eggnog. 

Rest  should  be  enjoined  to  suit  the  individual  case.  Not  less  than 
eight  hours  of  sleep  should  be  required  of  all,  and  in  many  instances 
a  midday  nap  of  one  or  two  hours  should  be  added.  A  girl  suffering 
from  severe  menstrual  pains  should  be  kept  quietly  at  home  while 
menstruating.  While  suffering  severe  pain  she  should  be  kept  in  bed. 
As  the  general  health  improves  the  pain  will  usually  lessen  and  more 
liberties  may  be  granted. 

Outdoor  exercise  should  be  indulged  in  and  encouraged  for  the 
purpose  of  improving  the  general  resistance.  No  restrictions  should 
be  placed  upon  the  desire  for  any  healthful  exercise.  In  the  intervals 
between  menstrual  periods  several  hours  a  day  should  be  devoted  to 
such  exercises. 

Regulation  of  the  bowels,  particularly  just  preceding  and  during 
the  menstrual  flow,  is  an  important  factor  in  relieving  painful  men- 
struation. The  giving  of  saline  cathartics  at  such  times  will  do  much 
in  relieving  pain. 

A  hot  hip  bath  or  full  tub  bath,  at  a  temperature  of  110°  F.,  taken 
for  a  half-hour  at  the  beginning  of  the  premenstrual  symptoms,  will 
do  much  to  prevent  the  onset  of  pain  and  to  promote  a  free  menstrual 
flow.  Great  care  should  be  exercised  in  preventing  a  chill  of  the  body 
upon  leaving  the  bath.  The  room  should  be  warm,  and  after  leaving 
the  bath,  the  body  should  be  hurriedly  dried  with  a  soft  towel  and 
wrapped  in  a  warm,  blanket  and  finally  there  should  be  an  hour  or  more 
of  rest  in  bed  following  the  bath. 

The  hot-water  bag  placed  over  the  hypogastrium  is  usually  sufficient 
in  itself  to  control  pain,  and  is  a  most  acceptable  substitute  for  drugs. 
The  hot  vaginal  douche  and  hot  saline  rectal  injections  are  helpful 


50  DISORDERS  ASSOCIATED  WITH  MENSTRUATION 

adjuncts  to  the  hot  bath.  A  hot  mustard  foot  bath  is  a  domestic  remedy 
of  some  value;  two  teaspoonfuls  of  mustard  are  placed  in  a  pail  of  hot 
water. 

()})iates  and  alcoholics  are  seldom  necessary  and  are  capable  of  much 
harm.  Many  women  have  become  addicted  to  opium  and  to  alcohol 
by  their  injudicious  use  in  controlling  pain  at  the  menstrual  periods. 
]\Iany  of  the  patent  remedies  advertised  for  the  cure  of  menstrual  dis- 
orders contain  a  large  percentage  of  alcohol.  The  Massachusetts  State 
Board  estimated  the  percentage  of  alcohol  in  Lydia  Pinkham's  Vege- 
table Compound  as  20.6;  in  Peruna,  28.5;  Pain's  Celery  Compound, 
21;  Ayer's  Sarsaparilla,  26.2.  When,  in  the  judgment  of  the  physi- 
cian, alcohol  or  opium  is  required  the  precaution  should  be  taken  to 
prescribe  them  in  such  a  manner  as  to  make  it  impossible  to  have  the 
prescription  refilled  or  for  the  patient  to  know  what  she  is  taking.  The 
following  are  favorite  prescriptions  for  the  relief  of  menstrual  pain: 

I^ — Aspirin 5j  41 

Veronal 5j  4|       — M. 

Ft.  caps.  no.  xii. 

Sig. — One  every  foiu-  hours. 

I^ — Phenacetin gr.  ij  103 

Salol gr.  ij  |03  — M. 

Ft.  charta.  Mitte  tales  no.  vi. 

Sig. — One  pow.der  every  four  hours. 

I^ — Phenacetin gr.  v  01 325 

Codein gr.  v  o|325— M. 

Ft.  charta.  Mitte  tales  no.  vi. 

Sig. — One  powder  and  repeat  in  an  hour. 

I^— Aspirin gr.  iij  0 1 195 

Phenacetin gr.  iij  0|l95— M. 

Ft.  tal.  caps.  no.  xx. 

Sig. — One  every  three  hours. 

]^— Apiol gr.  j  0|065— M. 

Ft.  caps.  no.  xii. 

Sig. — One  night  and  morning  for  three  days  before  menstruation. 

I^ — Acetanilid gr.  ij  0113 

Heroinse. '.      '.     gr.  i  0  01  — M. 

l*t.  cap.  no.  VI. 

Sig. — One  every  two  hours  for  three   doses. 

I^ — Sodii  bromid gr.  xl  2 1 6 

Hot  saHn  sol.  (physiological)  ....  Oj  "i       M 

Sig. — Inject  into  rectum  and  retain.     (Kelly.) 

I^ — Tr.  opii  camphorata 3j  4 Ice. 

Spt.  chloroformi       .            .      .            .      •  3ij  8  c  c' 

Aq^menth.  pip               .      .      .       q.  s.  ad  giv  120^0! 

big. — One  tea.spoonful  as  required. 

I^-Acetanili'd  gr.  ij  Jl30gm. 

Ft.pirr'i'"'' ^^•"^'  Il94gm.-M. 

Sig. — One  pill  every  hour  for  three  doses. 


DYSMENORRHEA  51 

I^ — Ergotin gr.  xxx  1 1 94  c.c. 

Stypticin gr.  xxx  1 1 94  c.c. 

Div.  in  caps.  no.  xx. 

Sig. — One  capsule  every  six  hoiu's  dm-ing  menstruation. 

I^ — Strontii  bromid 5iv  15 '52  c.c. 

Syrup  acacise giij  90 1       c.c. 

Sig. — Teaspoonful  in  water  every  three  hours. 

When  pain  is  associated  with  the  expulsion  of  blood-clots,  Bandler 
recommends  stypticin  in  2-grain  doses  repeated  several  times  daily. 
When  the  uterus  is  relaxed,  as  in  muscular  insufficiency,  ergot  may 
be  given  in  small  and  repeated  doses. 

When  pain  is  of  a  congestive  character  the  pelvis  is  depleted  by  such 
means  as  sitz  baths,  hot  hip  packs,  hot  vaginal  douches,  saline  catharsis, 
and  the  application  of  a  hot  mustard  plaster  to  the  spine.  A  plaster 
three  inches  in  width  is  placed  on  the  spine  from  the  neck  to  the  sacrum. 
The  following  method  is  used  in  preparing  the  plaster:  mustard  is 
rubbed  into  a  thick  paste  by  adding  warm  water  and  reduced  to  a  thick 
consistency  by  adding  molasses  or  syrup.  A  piece  of  unstarched  muslin 
about  24  inches  long  and  9  to  10  inches  wide  is  spread  through  the 
middle  third  and  the  lateral  thirds  of  the  muslin  are  folded  over  the 
mustard  paste.  After  warming  the  plaster  it  is  applied  the  length  of 
the  spine  for  ten  to  twenty  minutes  and  then  removed.  Emmet  believes 
that  dry  cups  are  more  efficacious  than  the  mustard  plaster.  Four 
to  six  large  tumblers  may  be  used.  They  are  to  be  placed  over  all 
tender  points  along  the  spine  and  left  in  place  for  fifteen  minutes. 

SuEGiCAL  Treatment. — When  tentative  measures  fail  to  afford 
relief  the  final  resort  must  be  to  surgical  intervention.  A  very  large 
proportion  of  cases  are  due  to  pelvic  lesions  which  are  only  amenable 
to  surgery.  In  order  that  tentative  measures  on  the  one  hand  and 
surgical  measures  on  the  other  may  be  wisely  ordered,  there  must  be 
a  thorough  appreciation  of  the  social,  moral,  and  physical  conditions 
affecting  the  individual.  Without  this  understanding  there  can  be 
no  intelligent  management  of  this  class  of  cases. 

Dilatation  of  the  Cervix. — The  one  operation  that  has  been  generally 
approved  in  the  management  of  dysmenorrhea  is  dilatation  of  the 
cervix.  Even  when  there  is  no  known  anatomical  basis  for  the  pain, 
the  overstretching  of  the  cervix  will  often  eft'ect  a  cure.  Kelly  dilated 
95  such  cases  and  obtained  permanent  relief  in  18  and  great  benefit 
in  14;  7  more  were  partially  or  completely  relieved  for  from  one  to 
twelve  years  when  the  pain  returned.  It  is  not  clear  just  how  these 
results  are  brought  about.  The  probable  explanation  is  in  the  over- 
stretching of  the  cervix,  which  overcomes  the  spastic  contractions 
which  cause  a  temporary  obstruction  to  the  menstrual  flow.  By  refer- 
ence to  the  many  factors  contributing  to  pain  at  the  menstrual  period 
it  is  apparent  that  dilatation  of  the  cervix  is  limited  in  its  applicability. 
No  good  can  come  from  dilatation  in  many  of  the  displacements,  inflam- 
mations, degenerations,  and  new-formations  of  the  pelvic  organs.  The 
technic  of  dilatation  and  curettage  is  described  in  Chapter  VII. 


52 


DISORDERS  ASSOCIATED  WITH  MENSTRUATION 


It  would  be  well  to  discuss  dilatation  and  curettage  in  the  treatment 
of  dysmenorrhea  because  this  procedure  is  so  frequently  resorted  to. 
Failure  to  effect  relief  is  not  so  much  ascribed  to  faulty  technic  as  to  a 
faulty  diagnosis.  The  existence  of  a  retrodisplacement  or  prolapsus  of 
the  uterus,  of  a  subinvolution  or  chronic  metritis,  of  an  inflammatory 


Fig.  5 


Conical  cervix,  punctiform  orifice.     (Pozzi.) 

involvement  of  the  adnexse  or  of  fibroid  tumors,  pelvic  exudates  or 
cystic  ovaries,  not  recognized  or  not  given  due  consideration,  renders 
dilatation  and  curettage  ineffective  and  often  harmful. 

The  uterus  should  be  dilated  and  curetted  in  the  presence  of  an 
existing  endometritis,  or  of  a  marked  anteflexion  and  as  a  sole  measure 


DYSMENORRHEA 


53 


it  should  be  employed  only  in  the  absence  of  other  pathological  lesions. 
When  relief  is  afforded  for  a  number  of  months  or  years,  and  pam 
ao-ain  returns,  a  second  dilatation  and  curettage  will  be  indicated. 

^Primary  dysmenorrhea  is  relieved  in  many  instances  by  dilatation 
of  the  cervix  and  curettage.    In  the  absence  of  a  pathological  lesion 


Fig.  6 


Hollowing  out  of  the  cut  surfaces  of  the  cervix.     (Pozzi.) 

the  results  gained  must  be  due  to  suggestion.    The  presence  of  anemia 
malnutritiol  and  neurasthenia  does  not  necessarily  -tigate  ^^^^^^ 
the  good  results  to  be  obtained  from  this  procedure      Inasmuch   as 
t  is  not  possible  to  foretell  which  cases  will  be  ^-f  jf^  a"^^ 
not,  it  would  seem  wise  to  subject  all  cases  to  dilatation  and  curettage 
which  cannot  be  controlled  by  more  tentative  measures. 


54 


DISORDERS  ASSOCIATED  WITH  MENSTRUATION 


Membranous  dysmenorrhea  presents  a  very  discouraging  prognosis. 
Curettage  and  the  appHcation  of  various  chemicals  have  been  tried 
with  Httle  result. 

Stem  Pessary. — The  stem  pessary  has  been  recommended  for  the  cure 
of  dysmenorrhea  associated  with  anteflexion  of   the  uterus;    but  the 


Fig.  7 


Introduction  of  the  stitches.     The  commLssural  stitches  are  drawn  tight.     (Pozzi.) 


author  has  no  personal  experience  with  this  contrivance  and  does  not 
look  upon  it  with  favor. 

Removal  of  the  Ovaries. — Should  apparently  healthy  ovaries  be 
removed  for  relief  from  dysmenorrhea?  The  author  has  never  met 
with  a  case  that  seemed  to  him  to  justifiy  such  a  procedure,  and  he 


DYSMENORRHEA 


55 


very  much  questions   if  [the   operation   is   ever   justified  under  such 

'"^He'^ild  here  quote  Kelly  and  add  his  personal  indorsement: 
"(Sphorectomv,  which  is  still,  I  fear,  too  often  done  for  mtractable 
d?sr^errhea,'i;  rarely,  if  ever  justifiable.    Let  the  younger  surgeon 

Fig.  8 


The  operation  finis 


u        rlrn-n-Ti  tio-ht  and  the  leaden  guards  applied. 
,hed.     All  stitches  have  been  drawn  tignc  anu 
(Pozzi.) 


be  assured  that  he  may  thus  transform  a  ueurotic  "jf^^t.  a  gloomy 
wreck,  fitted  only  for  an  asylum^  "■'>7,  f^.f  jh^tfe  who  comes  to 

h^afVoi'' hijL%  r;;?shoSf l:  ^:^^  -  -  -■  - 


56  BACKACHE 

the  after-state  of  the  patient  is  worse  than  the  first.  It  is  better  that 
ten  women  should  continue  to  endure  periodical  suffering  for  which 
he  is  not  responsible,  than  that  he  should  cure  nine  and  put  one  in  an 
asylum." 

Dysmenorrhea  Due  to  a  Conical  Cervix. — ^A  very  common  cause  of 
sterility  and  dysmenorrhea  is  said  to  be  found  in  a  conical  cervix  in 
which  the  external  os  is  very  small.  This  condition  is  an  arrest  of 
development  and  is  commonly  associated  with  an  arrest  of  develop- 
ment of  the  body  of  the  uterus  (infantile  uterus).  The  cervix  is  rela- 
tively long  and  is  flexed  forward,  thereby  affording  additional  cause 
for  dysmenorrhea  and  sterility. 

Figs.  5,  6,  7,  and  8,  from  an  article  by  Pozzi,^  present  the  technic 
of  the  operation  of  Pozzi  for  the  correction  of  this  condition.  The 
operation  should  be  preceded  by  dilatation  and  curettage.  Pozzi 
claims  for  this  operation  that  he  has  invariably  relieved  dysmenor- 
rhea and  that  pregnancy  has  followed  in  more  than  25  per  cent,  of 
his  cases. 

BACKACHE 

Causes 

Treatment 

coccygodynia 

Pain  in  the  back  is  so  frequent  a  complaint  of  women  as  to. demand 
special  consideration.  Backache  is  not  common  in  the  young  or  in 
the  aged,  but  occurs  with  great  frequency  between  the  ages  of  thirty 
and  fifty. 

Causes. — It  is  a  matter  of  common  observation  that  the  correction 
of  pelvic  disorders,  notably  of  retrodisplacements  of  the  uterus,  does 
not  always  relieve  backache.  This  suggests  two  things:  (1)  That 
uterine  displacements  do  not,  as  a  rule,  cause  backache,  contrary  to 
popular  opinion,  and  (2)  that  the  causes  of  backache  are  varied  and 
oftentimes  obscure.     Following  are  the  usual  causes: 

Lumbago. — Lumbago  is  the  result  of  exposure  and  muscular  strain. 
The  onset  is  usually  sudden  and  the  pain  and  discomfort  are  most 
distressing.  The  treatment  consists  of  heat  applied  to  the  lumbar 
region  in  the  form  of  hot-water  bags,  ironing  the  muscles  with  a  hot 
iron  for  several  minutes,  massage  of  the  lumbar  muscles,  rest  in  bed, 
and  the  administration  of  10  to  20  grains  of  aspirin,  every  two  to 
four  hours,  until  the  pain  is  under  control,  and  thereafter  5  grains 
every  two  to  four  hours. 

Nervous  Exhaustion. — Nervous  exhaustion  is  almost  invariably  asso- 
ciated with  backache.  The  pain  is  usually  referred  to  the  Jumbar 
region. 

Pelvic  Tumors  and  Inflammatory  Exudates. — These  cause  backache 
which  may  radiate  to  one  or  both  thighs.  Pain  in  the  back  which 
radiates  to  the  thigh,  suggests  the  probable  presence  of  an  incarcerated 

1  Surg.,  Gyn.,  and  Obst.,  August,  1909. 


CAUSES  57 

or  adherent  tumor  or  inflammatory  mass  in  the  pelvis  encroaching 
upon  the  sacral  nerves. 

Prolapse  of  the  Ovary. — When  the  ovary  lies  behind  the  uterus  pain 
is  commonly  referred  to  the  sacro-iliac  joint  of  the  respective  side.  The 
author  has  demonstrated  this  repeatedly  by  correcting  the  position  of 
the  ovary. 

Retroflexion  of  the  Uterus. — Retroflexion  of  the  uterus  is  a  cause  of 
backache,  but  not  to  the  extent  generally  believed. 

Postoperative  Backache. — Postoperative  backache  is  a  preventable 
complaint.  It  is  due  to  strain  upon  the  interspinous  ligaments  as  the 
patient  lies  upon  a  hard  operating  table  without  pad  or  cushion  to 
support  the  back.  Furthermore,  the  ligaments  of  the  sacro-iliac  joints 
are  also  unduly  strained  by  forcible  abduction  of  the  thighs  with  the 
legs  in  supports  and  the  patient  in  the  dorsal  position  for  vaginal 
operations. 

Mobility  of  the  Sacro-iliac  Joint. — Many  of  the  backaches  are  attrib- 
utable to  luxation  of  the  sacro-iliac  joint. 

Static  Backache. —  It  is  now  generally  recognized  that  relaxation 
of  the  sacro-iliac  joint  gives  rise  to  backache  that  was  formerly  ascribed 
to  viterine  displacements  and  other  pelvic  lesions.  Albree  has  demon- 
strated the  sacro-iliac  joint  to  be  a  true  joint  which  normally  permits 
of  a  limited  degree  of  motion.  If,  for  one  reason  or  another,  the  liga- 
ments of  the  joint  become  relaxed  there  will  be  an  undue  mobility  of 
the  joint  with  consequent  pain. 

Reynolds  and  Lovett^  ascribe  certain  forms  of  chronic  backache 
to  strain  upon  the  muscle  of  the  back,  caused  by  an  undue  effort  to 
maintain  the  body  balance.  They  endeavor  to  show  that  the  centre 
of  gravity  of  the  body,  in  the  erect  posture,  lies  in  front  of  the  ankle- 
joints,  knees,  sacro-iliac  joints,  and  most  of  the  vertebral  joints.  The 
factors  operating  in  the  maintenance  of  the  erect  posture  are  chiefly 
the  hamstrings,  the  glutei,  and  the  erector  spinse  muscles.  If  for  any 
reason  the  centre  of  gravity  moves  forward  a  strain  is  placed  upon 
the  posterior  musculature.  Authors  have  investigated  the  influence 
of  corsets  and  "high-heeled  shoes  upon  the  balance  of  the  body.  A 
properly  fitting  corset  should  fit  tightly  between  the  trochanters  and 
iliac  crests,  it  should  fit  the  hollow  of  the  waist  snugly,  and  above  the 
waist  it  should  be  worn  loosely.  The  front  should  be  straight  and 
without  constriction  at  the  waist  line.  No  corset  should  be  worn  that 
is  not  comfortable;  after  putting  on  the  corset  as  low  as  possible  and 
before  it  is  laced,  the  wearer  should  pass  the  hand  inside  and  lift  the 
abdomen,  and  at  the  same  time  tighten  the  laces  from  below  upward. 

High-heeled  shoes  tip  the  body  backward,  and  hence  add  to  the 
comfort  of  a  well-fitting  corset  and  lessen  the  discomfort  of  a  poorly 
fitting  corset.  This  is  so  because  the  muscles  of  the  back  are  relieved  of 
the  strain  caused  by  the  corset  throwing  the  centre  of  gravity  backward. 

Causes. — ^Meisenbach  classifies  the  causes  of  relaxation  of  the  sacro- 
iliac joint  in  women  as  follows: 

1  Jour.  Amer.  Med.  Assoc,  March  26,  1912. 


58  BACKACHE 

Trauinati.sms. — A  blow  or  a  fall,  relaxation  and  strain  from  faulty 
position  under  anesthesia;  long  and  rough  riding  on  horseback  or  in 
automobiles  are  the  tramnatic  factors  mentioned. 

General  DehUity. — General  debility,  following  wasting  diseases  and 
acute  illness,  such  as  typhoid  fever;  under  such  circumstances  both 
joints  are  usually  involved. 

Uterine  Disorders. — Uterine  disorders  associated  with  pelvic  con- 
gestion. The  condition  commonly  follows  pregnancy,  particularly-  a 
difficult  labor  in  which  high  forceps  are  used. 

Neuroses. — Backache  occurs  in  women  of  highly  excitable  tempera- 
ment. It  is  said  that  the  periods  of  intermittent  relaxation  appear  at 
times  to  cause  a  strain  of  the  joint.  To  the  author  this  explanation 
seems  vague. 

Diagnosis. — The  .r-rays  are  of  little  service  in  making  a  diagnosis 
of  luxation  of  the  sacro-iliac  joint,  but  the  stereoscopic  radiograph  is  of 
great  value.  The  treatment  consists  in  the  application  of  a  plaster  or 
celluloid  jacket  of  steel  braces,  elastic  webbing,  etc.  Such  cases  should 
be  referred  to  the  orthopedist. 

Gonorrheal  Arthritis. — Gonorrheal  arthritis  affecting  the  sacral  joints 
is  an  occasional  cause  of  backache. 

Faulty  Dress.  —  Faulty  dress  is  responsible  to  a  great  degree  for 
backaches  complained  of  by  women.  This  subject  is  discussed  in 
Chapter  XII. 

Gastro-enteroptosis. — Gastro-enteroptosis,  with  general  relaxation  of 
the  pelvic  supports,  produces  a  feeling  of  heaviness  in  the  pelvis  and 
a  weak  back. 

Treatment. — In  the  management  of  these  cases  it  is  important  to 
recognize  the  nervous  element  and  the  lack  of  general  nutrition  on  the 
part  of  women  complaining  of  backache.  Without  an  improvement 
in  the  general  state  of  health  little  good  can  come  from  correcting  the 
local  conditions.  This  is  accomplished  by  giving  a  suitable  mixed 
diet,  by  directing  a  systematic  course  of  exercise  within  doors  and 
outdoors,  by  stimulating  morning  baths,  and  by  skilful  massage  of  the 
muscles  of  the  back. 

General  tonics,  notably  nux  vomica  in  5-drop  doses,  increased  3 
drops  a  day  until  25  drops  are  taken  before  each  meal,  is  recommended 
by  Kelly.    Static  electricity  is  beneficial. 

The  correction  of  pelvic  lesions  which  contribute  to  backache  calls  for 
depleting  treatment  in  pelvic  inflammations,  for  pessaries  in  movable 
displacements  of  the  uterus,  and  for  surgical  interference  in  lesions  which 
are  only  amenable  to  surgery.  Careful  consideration  must  be  given  to 
the  manner  of  dress  and  the  personal  habits  of  the  individual. 

Coccygodynia. — Coccygodynia  is  a  term  applied  to  pain  referred  to 
the   coccyx. 

Direct  injury  from  a  blow,  a  fall,  or  from  the  strain  of  labor  is  the 
usual  cause.  It  is  probable  that  rheumatism,  especially  of  gonorrheal 
origin,  plays  an  important  part  in  the  etiology  of  this  affection. 

The  disease  has  been  called  the  "sitting  pain,"  because  of  the  dis- 


DIASTASIS  RECTI:  ENTEROPTOSIS 


59 


comfort  and  sometimes  unbearable  pain  experienced  in  sitting.  Walking 
and  standing  do  not,  as  a  rule,  cause  much  discomfort.  Pressure  upon 
the  cocc^'x  by  the  examining  finger  either  from  without  or  through 
the  rectum  will  locate  the  seat  of  pain.  Defecation  is  often  painful, 
and  especially  when  there  is  constipation. 

Treatment  consists  in  improving  the  general  health  through  hygienic 
means,  of  applying  the  faradic  current,  and  of  massaging  the  cocc\tc 
by  gentle  manipulations;  if  these  methods  fail  to  give  relief,  the  coccyx 
must  be  removed. 

In  the  management  of  coccygodynia,  palliative  treatment  and  even 
resection  are  often  unsatisfactory.  ]\Iassage  of  the  coccyx  is  productive 
of  the  best  result.  The  bone  is  held  between  the  forefinger  in  the  rectum 
and  the  thumb  on  the  outside;  it  is  then  moved  backward  and  forward 
and  the  soft  parts  are  moved  about  on  the  bone.  Immediate  improve- 
ment will  usuallv  follow. 


Fig.  9 


Demonstration  of  the  separation  of  the  resti  inu-  le-  in 


DIASTASIS  RECTI:  ENTEROPTOSIS 


Causes 
Symptoms 

Teeatmext 


Patients  suffering  from  enteroptosis  commonly  complain  of  back- 
ache, pain  in  one  or  both  kidneys,  general  dragging  sensations  in  the 
abdomen,  dyspeptic  symptoms,  and  general  nervousness. 


60 


DIASTASIS  RECTI:  ENTEROPTOSIS 


On  physical  examination  the  abdominal  wall  is  found  to  be  relaxed, 
permitting  of  deep  indentation  between  the  widely  separated  recti 
muscles.  When  in  the  standing  position  the  abdomen  is  pendulous, 
and  on  straining  or  coughing  there  is  marked  protrusion  between  the 
recti  muscles. 

In  these  cases  it  is  not  enough  to  correct  the  relaxed  and  torn  sup- 
ports of  the  pelvic  floor.     The  profession  is  indebted  to  J.  Clarence 


Fig.  10 


Marked  separation  o(  the  recti  muscles.     The  fist  is  buried  in  the  gap  between  the  separated 

muscles. 

Webster  for  calling  attention  to  this  important  defect.  The  greatest 
point  of  stretching  of  the  fascia  is  usually  at  the  umbilicus,  but  may 
extend  the  entire  length  of  the  central  line  from  the  symphysis  to  the 
pubis.  This  stretching  of  the  fascia  may  separate  the  recti  muscles 
from  two  to  five  inches. 

Causes. — Childbearing  is  the  predominating  factor.  This  is  particu- 
larly true  when  there  is  a  succession  of  pregnancies.  Heavy 'lifting 
increases  the  defect  and  malnutrition  is  an  important  predisposing 
factor. 

Fig.  11 


In  this  scheme  the  abnormal  separation  of  the  recti  muscles  is  shown,  which  permits  a 
hernia-like  projection  of  the  viscera. 

Symptoms. — The  symptoms  commonly  complained  of  are  backache, 
dragging  sensations  in  the  abdomen,  a  sense  of  weight  and  insecurity 
in  the  pelvis,  a  feeling  of  fatigue  on  moderate  exertion,  dyspepsia, 
general  nervousness,  constipation,  and  pain  in  the  iliac  and  lumbar 
regions.  The  pulsations  of  the  aorta  are  often  distressing.  It  is 
sometimes  desirable  to  place  the  patient  in  the  standing  posture  for 


TREATMENT 


61 


the  purpose  of  inspecting  the  abdomen.    In  this  position  a  pendulous 
abdomen  is  best  inspected. 

The  body  is  draped  with  a  sheet  from  the  hips  down;  the  remainder 
of  the  body  is  stripped.  The  flat  chest,  the  depressed  epigastrium, 
the  long  vraist,  the  drooping  shoulders,  the  general  flabby  muscular 
development,  and  the  prominent  abdomen  are  then  noted. 


Fig.   12 


Operation  for  repair  of  -n-eakened  abdominal 
-svall.  The  drawing  represents  the  inner  edges 
of  the  separated  recti  muscles  exposed.  A, 
stretched  and  thinned  linea  alba;  B,  anterior 
layer  of  sheath  of  rectus;  C,  edge  of  rectus 
muscle  exposed  by  opening  sheath;  D,  skin 
and  subcutaneous  tissue.     (Webster.) 


*  I     I 


i 


The  drawing  represents  the  recti  muscles 
-with  the  fascia  covering  them  drawn  together 
and  sutured  by  strong  hnen.  A,  fascia  form- 
ing anterior  sheath  laj^ers  of  rectus;  B,  line  of 
juncture  of  the  muscles  and  sheaths;  C,  skin 
and  subcutaneous  tissue.     (Webster.) 


Treatment.— When  the  diastasis  is  of  moderate  degree  the  condi- 
tions mav  be  remedied  by  discarding  a  faulty  corset,  by  suspending 
the  clothing  from  the  bust  and  shoulders,  by  systematic  exercises,  and 
the  proper  regulation  of  the  diet.  Abdominal  supports  may  bring 
relief,  but,  as  Webster  says,  they  are  objectionable  because  they 
produce  atrophy  and  weakening  of  the  trunk  muscles,  and  they  are 
uncomfortable  to  wear  in  hot  weather.  _ 

Technic  of  Operation.— Webster  makes  a  median  abdominal  incision 
corresponding  in  length  to  the  line  of  separation.    The  umbilicus  may 


62 


DIASTASIS  RECTI:  ENTEROPTOSIS 


or  may  not  be  excised.  The  skin  and  subcutaneous  fat  are  dissected 
from  the  underl.vmg  fascia  to  the  margins  of  the  .separated  rectf  The 
fasca  ,s  then  spht  from  beloiv  upward  at  the  attachment  to  The  recti 
muscles;  the  muscles  are  dissected  from  the  underlving  fascia  and  are 
then  approximated  m  the  median  line  by  interrupted  linen  s.m.res 
Catgut  may  be  used  to  complete  the  approximation.  When  t  lere  fa 
an  undue  amount  of  redundant  skin,  this  may  be  removed  in  a  strip 
from  either  side  and  the  margins  sutured  in  the  usual  manner 


^      CHAPTER  III 
LEUCORRHEA— STERILITY— THE  MENOPAUSE 


LEUCORRHEA 


NoEMAL  Secretions  of  the  Genital 

Organs 
Clinical    Grouping    According    to 
Age 
In  Infants 
In  Virgins 


In  Period  of  Sexual  Maturity 

In  Old  Women 
Diagnosis 

Odor 
Treatment 


Any  discharge  from  the  vulva  that  is  not  blood  is  popularly  called 
"whites"  or  leucorrhea.  When  the  secretion  departs  from  the  normal 
in  color,  consistency,  odor,  irritability,  and  amount,  there  must  exist 
either  a  functional  or  an  organic  lesion  of  the  genital  organs.  Hence 
it  is  of  the  greatest  importance  to  determine  the  character  and  source 
of  the  secretion. 

The  Normal  Secretions  of  the  Genital  Organs. — These  are:  1. 
From  the  vulva  the  ordinary  secretions  are  those  of  the  sebaceous  and 
sweat  glands.  The  Bartholinean  glands  lying  in  the  labia  majora  secrete 
mucus,  particularly  during  sexual  excitement.  The  reaction  is  alkaline, 
and  the  amount  is  scarcely  noticeable. 

2.  The  vagina  does  not  ordinarily  contain  glands,  but  occasionally  a 
few  are  found  in  the  vault  of  the  vagina.  The  vagina  has  essentially 
a  skin  surface,  having  no  secretion  under  normal  conditions.  The 
so-called  vaginal  secretion  is  the  accumulated  outpour  of  the  uterine 
body  and  cervix  mixed  with  epithelium  and  bacteria.  The  secretion 
is  acid  in  reaction  as  the  result  of  the  action  of  certain  bacteria  which 
change  the  alkaline  secretion  of  the  uterus  to  an  acid  reaction. 

3.  The  secretion  of  the  cervix  is  mucus.  It  is  tenaceous  and  slightly 
alkaline  in  reaction. 

4.  The  secretion  of  the  endometrium  is  serous  and  sufficient  in 
amount  to  moisten  the  surface;  it  is  mildly  alkaline,  clear,  and  trans- 
parent. 

Clinical  Grouping  According  to  Age. — For  clinical  purposes  leucor- 
rhea will  be  considered  as  it  occurs  in  the  various  periods  of  life. 

In  Infants. — In  children  a  leucorrhea!  discharge  seldom  arises  from 
a  point  above  the  hymen.  As  a  rule  it  is  the  expression  of  a  vulvitis, 
which  in  turn  is  caused  by  soiled  diapers,  intestinal  worms,  highly 
acid  urine,  gonorrhea,  masturbation,  and  the  strumous  diatheses.  The 
vulva  appears  swollen  and  reddened,  is  tender,  and  is  covered  by  a 
slimy  secretion. 


64  LEUCORRHEA 

In  Virgins. — In  young  girls  it  is  not  unusual  for  a  transient  leucorrhea 
to  appear  from  time  to  time.  No  pathological  basis  for  the  leucorrhea 
can  be  discovered  further  than  a  possible  pelvic  congestion.  Persistent 
leucorrhea  may  be  due  to  the  same  causes  found  in  childhood.  As 
in  infants,  the  contributing  lesion  is  commonly  a  vulvitis,  and  is  rarely 
found  above  the  hymen.  The  secretion  is  seldom  sufficient  to  more 
than  moisten  the  vulva,  and  rarely  calls  for  a  local  examination. 
Anemia  is  always  to  be  considered  in  determining  the  contributing 
factors. 

ti  the  Period  of  Sexual  Maturity. — The  secretion  may  come  from  any 
portion  of  the  genital  tract — from  the  vulva,  vagina,  cervix,  body, 
and  tubes.  In  the  vast  majority  of  cases  the  cause  may  be  ascribed 
to  gonorrhea  and  to  labor  and  abortion.  The  most  profuse  leucorrhea 
is  occasioned  by  gonorrheal  infection.  Among  other  causes  may  be 
mentioned  instrumental  and  digital  inspection,  displacements  of  the 
uterus,  passive  congestion  due  to  an  interference  with  the  return  supply 
of  blood  as  a  result  of  diseases  of  the  heart,  lungs,  liver,  kidney,  and 
spleen.  Abdominal  tumors,  acute  infectious  diseases,  and  all  benign 
and  malignant  new-formations  of  the  vulva,  vagina,  and  uterus  are 
contributing  factors  to  leucorrhea  at  this  time  of  life. 

Not  only  the  cause' but  the  source  of  the  secretion  must  be  deter- 
mined. Schultze  devised  the  following  method  of  demonstrating  the 
source  of  the  secretion:  Following  a  vaginal  douche  of  sterile  water 
a  large  tampon  of  sterile  absorbent  cotton  is  placed  against  the  cervix 
and  left  there  for  several  hours.  If  the  secretion  comes  from  the  uterus, 
it  will  collect  upon  the  top  of  the  tampon  and  can  be  examined  for 
bacteria  and  other  elements.  If  the  secretion  is  mucus  and  in  small 
amount,  it  must  come  from  the  cervix;  if  watery  and  abundant,  it  comes 
from  the  body  of  the  uterus,  rarely  from  the  tubes — "hydrosalpinx 
profluens." 

It  is  of  importance  to  distinguish  between  a  hypersecretion  of  the 
endometrium  and  a  discharge  due  to  some  pathological  lesion.  This 
is  often  difficult,  and  may  be  impossible.  Women  will  often  complain 
of  a  leucorrhea  immediately  before  and  after  the  menstrual  flow.  As 
a  result  of  the  congestion  which  precedes  the  monthly  flow  one  or 
more  days  and  continues  a  variable  time  after  the  cessation  of  the 
bloody  flow,  there  is  a  hypersecretion  of  the  glands  sufficient  to  give 
rise  to  a  seromucous  discharge. 

In  Old  Women. — In  the  aged,  leucorrhea  has  a  more  serious  signifi- 
cance. The  source  is  the  vulva,  vagina,  and  uterus.  Senile  vaginitis, 
vulvitis,  and  endometritis  are  the  most  common  causes. 

In  the  event  of  unusual  discharges  from  the  genital  tract  of  women 
advanced  in  years,  whether  the  discharge  be  watery,  bloody,  p^urulent, 
or  ichorous,  there  is  always  a  suspicion  of  malignancy,  and  this  thought 
is  uppermost  in  the  search  for  the  underlying  cause.  Gonorrhea  infect- 
ing the  .aged  rarely  involves  the  uterus  and  tubes.  The  infection  is 
generally  limited  to  the  vagina  and  urethra.  The  irritation  of  a  filthy 
and  ill-fitting  pessary  will  occasion  a  vaginal  discharge. 


TREATMENT  65 

Malignant  growths  produce  at  first  a  watery  discharge,  which  later 
becomes  turbid,  bloody,  and  foul-smelling.  Cancer  of  the  body  of 
the  uterus  is  more  common  after  the  menopause  than  is  cancer  of  the 
cervix;  therefore,  in  seeking  the  cause  of  a  suspicious  discharge  occurring 
after  the  menopause  it  may  be  necessary  to  explore  the  uterine  cavity 
with  a  curet.  The  discharge  of  a  senile  endometritis  may  simulate 
that  of  a  malignant  growth,  and  nothing  short  of  an  exploratory 
curettage,  with  a  microscopic  examination  of  the  scrapings,  will  establish 
the  diagnosis. 

Odor  as  an  Aid  to  Diagnosis. — The  odor  of  the  vaginal  discharge  is 
sometimes  an  aid  to  diagnosis.  The  foul  odor  of  a  vaginal  discharge  sug- 
gests a  rectovaginal  fistula  or  a  complete  laceration  of  the  perineum.  A 
urinary  odor  to  the  vaginal  discharge  suggests  a  vesicovaginal  fistula. 
The  odor  of  a  discharge  from  a  cancerous  uterus  is  rather  characteristic 
but  cannot  be  distinguished  from  that  coming  from  a  sloughing  fibroid 
or  decomposed  placental  tissue. 

Treatment. — ^It  is  manifestly  unscientific  to  direct  the  treatment 
solely  to  the  relief  of  a  symptom  such  as  leucorrhea.  There  is  always 
a  pathological  basis  which  should  be  sought  for  and  if  possible  removed. 

It  must  be  borne  in  mind  that  certain  general  conditions  may  cause 
leucorrheal  discharges;  such  for  example  are  diseases  of  the  heart,  lungs, 
kidneys,  liver,  spleen,  constipation,  and  abdominal  swellings,  which 
may  create  a  pelvic  congestion  and  in  turn  produce  a  hypersecretion 
of  the  uterine  glands.  Faulty  excretions,  such  as  are  common  to  uremia, 
gout,  and  rheumatism,  are  also  to  be  considered.  The  treatment  in 
all  such  cases  is  carried  out  on  the  general  principles  laid  down  in 
treatises  on  internal  medicine.  In  general  it  may  be  said  that  the 
effort  should  be  made  to  restore  the  equilibrium  of  the  general  circulation 
by  the  removal  of  the  cause  of  the  embarrassment  to  the  circulation, 
and  so  to  regulate  the  diet  and  exercise  as  to  promote  assimilation  and 
favor  elimination. 

In  all  conditions  of  pelvic  congestion  dependent  upon  general  causes, 
local  depleting  measures  must  be  instituted  in  connection  with  the 
general  treatment.  These  include  hot  douches,  long  continued  and 
repeated  two  to  four  times  a  day,  glycerin  and  ichthyol  tampons,  and 
free  catharsis. 

By  referring  to  the  causes  of  leucorrhea  as  outlined,  it  will  be  apparent 
that  the  only  permanent  way  of  affording  relief  from  these  discharges 
lies  in  the  removal  of  the  cause.  As  temporary  and  palliative  measures 
certain  well-tried  procedures  may  be  adopted.  These  consist  in  cleans- 
ing vaginal  douches,  which  should  be  taken  in  the  recumbent  position 
one  or  more  times  daily.  Plain  sterile  water  at  a  temperature  of 
110°  F.  will  suffice,  for  this  purpose.  If  the  vaginal  portion  of  cervix, 
vagina,  and  vulva  are  infected  it  would  be  well  to  add  an  antiseptic 
to  the  douche.  For  this  purpose  the  author  prefers  formalin  in  solution 
of  1  to  2000;  lysol,  creolin,  or  bichloride  of  mercury  will  also  serve  the 
purpose. 

When  the  infection  lies  above  the  external  os  antiseptic  douches  will 


66  LEUCORRHEA 

have  little  advantage  over  plain  sterile  water,  inasmuch  as  the  douche 
water  does  not  reach  the  infected  area  and  only  serves  to  rid  the  vagina 
and  vulva  of  the  accumulated  secretions.  It  is  essential,  however, 
that  such  infective  secretions  be  kept  clear  of  the  vaginal  and  vulvar 
surfaces  lest  they  in  turn  become  infected. 

When  the  discharges  ha^•e  a  disagreeable  odor  formalin  is  efficient. 
Permanganate  of  potassium  is  also  a  good  deodorant.  For  the  treatment 
of  the  offensive  discharges  from  cancer  of  the  cervix  see  chapter  on  Treat- 
ment of  Inoperable  Cancer  of  the  Cervix.  When  necrotic  tissue  exists, 
as  in  decomposed  placental  tissue,  sloughing  fibroids,  and  malignant 
growths,  the  mechanical  removal  of  the  dead  tissue  by  means  of  the 
curette  and  fingers  is  the  first  step  in  the  correction  of  the  discharges. 
Following  this  procedure,  douches  of  hot  sterile  water  with  formalin  1 
to  1000  to  1  to  2000  or  permanganate  of  potassium  1  to  500  to  1  to 
1000  may  be  given. 

Pruritus  vulvae  is  aggravated  and  is  often  dependent  upon  irritating 
vaginal  discharges.  In  addition  to  vaginal  douches  a  dry  sterile  tampon 
of  lambs'  wool  or  a  boroglycerin  tampon  inserted  one  or  more  times 
daily  by  the  patient  or  nurse  will  prevent  discharges  from  soiling  the 
vulvar  surface. 

Nearly  all  leucorrheal  discharges  are  more  or  less  dependent  upon  a 
congestion  of  the  pelvic  organs,  and  hence  depleting  measures  are  of 
the  utmost  value.  Such  are  long-continued  hot  douches,  glycerin 
and  ichthyol  tampons,  and  the  free  evacuation  of  the  bowels. 

Finally,  it  must  be  again  remarked  that  leucorrhea  is  but  an  expression 
of  an  existing  lesion  or  physiological  disturbance,  and  hence  is  not 
to  be  treated  as  a  pathological  entity,  but  suggests  the  underlying 
cause  and  calls  for  a  searching  examination.  Having  found  the  cause 
and  effectively  directed  the  treatment  to  it  the  leucorrhea  will  be 
relieved.  The  author  has  found  little  or  no  satisfaction  in  internal 
medication  or  in  the  application  of  suppositories  for  the  relief  of 
leucorrheal  discharges. 

The  following  formulae  are  recommended  for  douche  solutions : 

I^— Lysol 3iv  120^ 

Sig. — Dessertspoonful  to  each  quart  of  hot  water.     (An  antiseptic  douche.) 

I^ — Potassii  permangan oiiss  lOjOO 

Aquse Bviij        240 1 00 

Sig. — Dessertspoonful  to  each  quart  of  hot  water.     (A  deoderizing  douche.) 

I^— Zinci  sulphatis 5j  30|00 

Div.  in  chart,  no.  xxx. 

Sig. — One  powder  dissolved  in  one  quart  of  hot  water.      (An  astringent 
douche.) 

I^— Aluminis giv  120:00 

Div.  in  chart,  no.  xxx. 

One  powder  dissolved  in  one  quart  of  hot  water.     (An  astringent  douche.) 

I^ — Acidi  tannici oss  lolOO 

Glycerini giv  120|00 

Sig. — Two  tablespoonfuls  to  one  quart  of  hot  water.    (An  astringent  douche.) 


STERILITY  67 

I^ — Liq.  plumbi  subacetatis §ss  15 

Tinct.  opii §j  30 

Aquae q.  s.  ad  §iv  120 

(A  sedative  lotion  for  local  application.) 

I^ — Zinci  sulphatis .     gr.  viij  1518 

Aquae oviij  240 1 

(A  sedative  lotion  for  local  application.) 


STERILITY 

Definitions  |  General  Causes 

Conditions  Essential  to  Conception  ■  Local  Causes 
Etiology  Treatment 

Definitions. — Before  entering  into  a  discussion  of  the  various 'causes 
of  sterility  in  women  the  clinical  significance  of  the  term  sterility  and 
the  conditions  essential  to  conception  should  be  clearly  understood. 

By  sterility  is  meant  an  incapacity  for  childbearing.  This  definition 
may  be  further  qualified  by  the  terms  "absolute  sterility"  and  "relative 
sterility."  Sterility  is  absolute  when  the  individual  is  incapable  of 
bearing  a  child  to  the  period  of  viability;  she  may  conceive  but  habitu- 
ally aborts  before  the  period  of  viability.  Sterility  is  relative  when 
childbearing  is  not  in  accordance  with  condition,  age,  and  length  of 
married  life.  Thus  the  term  relative  sterility  may  be  used  when  three 
years  have  elapsed  since  the  last  childbirth,  or  when  conception  has 
not  taken  place  within  three  years  from  date  of  marriage.  This  time 
limit  is,  of  course,  purely  arbitrary. 

M.  Duncan  found  that  in  one-sixth  of  all  cases  parturition  occurred 
before  the  lapse  of  the  first  year  after  marriage,  and  in  the  second 
year  four-sixths  of  all  marriages  were  fruitful. 

Again,  sterility  may  be  regarded  as  primary  and  secondary:  'primary 
when  the  conditions  which  preclude  the  possibility  of  childbearing  are 
primary,  and  secondary  when  after  the  birth  of  one  or  more  children 
there  is  an  acquired  incapacity  for  childbearing. 

Periods  of  fifteen  and  even  twenty  years  have  intervened  between 
successive  childbirths,  and  this  in  the  absence  of  any  apparent  cause 
for  sterility. 

One-child  Sterility. — The  term  one-child  sterility  is  applied  to  cases 
in  which  a  child  is  born  in  due  time  and  the  mother  is  thereafter  in- 
capable of  childbearing.  The  most  common  explanation  lies  in  a  latent 
gonorrheal  infection  which  preceded  the  pregnancy  or,  more  rarely, 
was  acquired  during  pregnancy.  Such  latent  infections  are  caused  to 
extend  from  the  cervix  to  the  body  of  the  uterus,  thence  to  the  tubes, 
ovaries,  and  pelvic  peritoneum.  In  such  an  event  sterility  is  almost 
the  inevitable  result.  Other  causes  are  lactation  atrophy,  puerperal 
non-gonorrheal  infections  of  the  uterus  and  its  appendages,  acquired 
displacements,  lacerations,  and  the  development  of  a  fibroid  tumor. 

Conditions  Essential  to  Conception. — The  conditions  essential  to 
conception  are  briefly  enumerated  as  follows: 


68  STERILITY 

1.  Deposit  of  semen  containing  living,  active  spermatozoa  in  the 
upper  segment  of  the  vagina. 

2.  Passage  of  the  spermatozoa  through  the  cervix  into  the  cavity 
of  the  uterus.  It  is  said  that  spermatozoa  will  not  live  longer  than 
twelve  hours  in  the  acid  secretions  of  the  vagina;  while  in  the  uterus 
and  tubes  they  commonly  retain  their  vitality  sLx  to  eight  days.  Leopold 
reported  a  ease  of  a  woman  in  his  clinic  who  had  not  had  sexual  inter- 
course for  thirty-seven  days  prior  to  the  operation,  when,  on  abdominal 
section,  living,  active  spermatozoa  were  found  in  large  numbers  in  the 
fimbriated  end  of  the  tube.  This  case,  with  many  other  observations 
on  women  and  lower  animals,  has  led  to  the  statement  that  fertilization 
of  the  ovum  commonly  takes  place  in  the  tube. 

3.  A  healthy  ovum  must  find  an  uninterrupted  passage  from  the 
ovary,  through  the  tube,  and  on  into  the  uterine  cavity. 

4.  The  fertilized  ovum  must  find  a  permanent  resting-place  on  the 
endometrium  until  the  period  of  viability. 

With  these  definitions  of  sterility  and  the  conditions  essential  to 
conception  clearly  understood,  it  is  now  possible  to  consider  the  factors 
which  tend  to  prevent  conception. 

Etiology. — In  seeking,  the  cause  of  sterility,  not  only  the  whole  range 
of  diseases  peculiar  to  women  must  be  considered,  but  as  well  the 
general  physical  and  social  conditions  of  the  individual.  More  than 
this,  the  cause  of  sterility  is  not  necessarily  found  in  the  woman ;  fully 
one  in  six  sterile  marriages  is  chargeable  to  the  husband.  One  marriage 
in  ten  is  non-productive,  and,  with  few  exceptions,  sooner  or  later  the 
advice  of  the  physician  is  sought.  The  subject  is  therefore  of  prime 
importance  to  the  physician,  and  no  condition  more  thoroughly  taxes 
the  skill  of  the  general  practitioner  and  specialist. 

General  Causes. — In  determining  the  cause  of  sterility  the  general 
conditions  predisposing  to  sterility  should  first  be  considered,  and  of 
these  age  is  the  most  important.  Xo  cause  of  sterility  approaches 
age  in  extent  and  power.  The  most  prolific  time  of  life  is  between 
the  ages  of  twenty  and  twenty-four.  Pregnancy  may  occur  before 
the  menstrual  period,  as  so  often  happens  in  India,  where  it  is 
considered  a  sin  to  let  pass  an  opportunity  for  conception — a  sin 
equivalent  to  infanticide.  Because  of  this  belief  it  is  customary,  in 
such  countries,  to  marry  before  puberty.  ^Marriages  occurring  between 
fifteen  and  twenty  years  of  age  are  relatively  sterile  as  compared  with 
those  occurring  between  twenty  and  twenty-five.  The  explanation 
lies  in  the  more  mature  development  of  the  sexual  organs  after  twenty 
years  of  age.  A  case  is  recorded  where  a  woman  gave  birth  to  twelve 
children  before  her  menstrual  flow  appeared.  Again,  it  is  possible  for 
pregnancy  to  occur  long  after  the  cessation  of  the  menstrual  period. 
Trento  reported  a  case  of  a  woman  who  gave  birth  to  a  child  at  sixty- 
seven  years  of  age.  xA.braham*  was  one  himdred  years  of  age  and  Sarah 
ninety  when  their  child  was  born.  Sarah  "was  old  and  well  stricken 
with  years,  and  with  whom  it  had  ceased  to  be  as  it  is  with  women" — 
that  is,  she  had  ceased  to  menstruate.    Renauden  reported  the  case  of 


ETIOLOGY  69 

a  woman  who  was  delivered  of  a  child  ten  or  twelve  years  after  the 
cessation  of  the  menstrual  periods.  So,  while  pregnancy  is  possible 
after  the  menopause,  the  rule  is  that  the  capacity  for  childbearing 
ceases  four  to  six  years  before  the  cessation  of  the  catamenia. 

Anemia. — Anemia,  either  primary  or  secondary  to  some  wasting 
disease,  such  as  tuberculosis,  diabetes,  nephritis,  and  malaria,  is  an 
important  predisposing  factor,  and  must  always  be  taken  into  account 
whatever  else  may  be  found. 

Coiuanguinity. — JNIarriage  of  near  relatives  is  said  to  be  a  cause  of 
relative  sterility,  but  this  statement  is  not  confirmed.  G.  Darwin  has 
proved  the  harmlessness  of  marriages  between  cousins,  and  has  demon- 
strated the  fertility  of  such  marriages. 

Obesity. — Obesity  is  undoubtedly  a  potent  cause  of  sterility.  That 
peculiar  form  of  obesity  associated  with  anemia  especially  conduces 
to  sterility.  Scanty  nutrition  has  little  or  no  influence.  ^Yhen  a  woman 
rapidly  increases  in  weight. she  very  often  becomes  sterile,  and  in  such 
the  most  promising  means  of  relieving  sterility  is  to  reduce  the  weight. 

AlcoJiolism. — Alcoholism  is  an  indisputable  factor;  furthermore,  the 
death-rate  among  children  born  of  inebriate  mothers  is  double  that  of 
temperate  parentage. 

Sexual  Instinct. — The  sexual  instinct  evidently  has  some  influence 
upon  the  fertility  of  women.  While  it  is  true  that  many  women  bear 
children  who  have  never  experienced  sexual  desire,  it  is  the  rule  that 
women  are  most  likely  to  conceive  who  have  the  greatest  sexual  vigor. 

Sexual  Excess. — Sexual  excess,  on  the  other  hand,  conduces  to  sterility 
through  the  congestion  and  inflammation  resulting  from  such  excesses. 

Sexual  Incompatibility. — Sexual  incompatibility  is  an  ill-defined 
condition  that  plays  a  role  in  the  causation  of  sterility,  though  no 
explanation  is  offered.  This  recalls  the  childless  marriage  of  Josephine 
and  Napoleon  and  the  fruitful  remarriage  of  both.  Many  unhappy 
yet  fruitful  marriages  disprove  this  theory.  As  a  rule  some  other 
explanation  for  the  sterility  is  found. 

Influence  of  Temjjerature  and  Climate. — The  action  of  heat  and  cold 
in  the  various  zones  does  not  appear  to  affect  fertility. 

Local  Causes. — After  this  consideration  of  the  general  predisposing 
causes,  the  more  tangible  local  factors  must  now  be  considered. 

Dyspareunia. — Dyspareunia  is  not  an  uncommon  cause  of  sterility, 
and  in  every  case  the  underlying  cause  of  painful  coition  must  be  deter- 
mined. Lesions  obstructing  the  lower  genital  passage,  such  as  acquired 
and  congenital  atresia  of  the  vulva  and  vagina,  must  be  looked  for,  as 
well  as  overgroT\-ths  of  the  labia  and  clitoris,  and  tumors  of  the  vulva, 
vagina,  and  uterus,  which  encroach  upon  the  lower  passages.  Other 
lesions  causing  pain,  such  as  urethral  caruncle,  inflammatory  lesions 
of  any  portion  of  the  genital  tract,  inflammation  of  the  urethra  and 
bladder,  and  painful  lesions  of  the  rectum,  including  fissures  and  hemor- 
rhoids must  also  be  looked  for.  Vaginismus  without  a  recognizable 
lesion  is  an  occasional  cause  of  dyspareunia.  It  is  not  essential  to 
conception  that  sexual  union  be  complete.     This  is  demonstrated  by 


70  STERILITY 

the  fact  that  pregnancy  may  occur  with  an  intact  hymen  and  in  the 
presence  of  other  evident  obstructions  to  complete  sexual  union. 

Maldeveloiyments  and  Malformations. — The  maldevelopments  and 
malformations  of  the  genital  organs  are  occasional  causes  of  absolute 
sterility.  The  absence  of  any  of  the  reproductive  organs  or  the  failure 
of  these  organs  fully  to  develop  are  certain  causes  of  sterility.  A 
uterus  partially  or  completely  divided  is  not  likely  to  become  pregnant, 
and  a  septum  dividing  the  vagina  may  offer  an  obstruction  to  sexual 
intercourse.  When  a  woman  complains  of  amenorrhea,  or  at  most  of 
a  scanty,  irregular  flow  which  has  persisted  from  a  delayed  puberty, 
it  is  highly  presumptive  that  the  uterus,  together  with  the  tubes  and 
ovaries,  has  failed  to  develop  beyond  the  infantile  type.  The  ovaries 
are  primarily  at  fault  in  the  majority  of  cases,  and  in  consequence  the 
uterus  fails  to  develop.  While  there  is  little  encouragement  in  treatment 
of  any  kind,  it  is  manifestly  illogical  to  direct  the  treatment  to  the  uterus 
rather  than  to  the  ovaries — a  procedure  akin  to  whipping  the  cart  to 
make  the  horse  go.  The  complete  closure  of  any  portion  of  the  genital 
tract  will  result  in  sterility,  but  these  conditions  are  rare,  with  the 
exception  of  closure  of  the  tubes  from  inflammatory  adhesions.  The 
influence  of  stenosis  in  causing  sterility  is  doubtless  exaggerated.  A 
congenital  narrowing  of  the  cervical  canal  prevents  the  passage  of 
spermatozoa,  but  in  such  cases  there  is  usually  an  underdevelopment 
of  the  uterus,  and  possibly  the  ovaries  as  well,  to  account  for  the 
sterility. 

The  vagina  may  be  too  short  or  too  narrow  to  retain  the  semen, 
and  the  cervix  may  be  too  long  to  allow  the  entrance  of  the  spermatozoa 
from  the  vault  of  the  vagina,  where  it  is  usually  deposited.  A  short 
cervix  per  se  is  not  a  cause  for  sterility;  occasionally  the  explanation  lies 
in  an  underdevelopment  of  the  uterus  associated  with  a  short  cervix. 

A  frequent  cause  of  secondary  sterility  is  superinvolution  of  the 
uterus  brought  about  by  superlactation,  infection,  or  malnutrition. 

Malyositions.- — Malpositions  as  direct  causes  of  sterility  have  been 
greatly  overrated.  Pregnancy  is  possible  in  all  malpositions  of  the 
uterus  with  the  exception  of  complete  inversion.  The  underlying  cause 
is  more  often  in  the  accompanying  inflammatory  lesions  and  in  dys- 
pareunia.  Chronic  endometritis  and  ovaritis  are  so  commonly  asso- 
ciated with  displacements,  and  are  such  potent  causes  of  sterility,  it 
is  fair  to  assume  that  they  are  most  often  the  underlying  causes. 

The  displaced  cervix  is  a  more  probable  cause  than  is  the  displaced 
body  of  the  uterus.  The  difficulty  with  which  the  semen  enters  the 
cervix  when  displaced  forward,  or  to  the  side  in  backward  or  lateral 
displacement  of  the  uterine  body,  will  account  for  sterility,  whereas 
it  is  difficult  to  conceive  of  the  cervical  canal  being  obstructed  by  the 
flexion  of  the  body  upon  the  cervix.  The  thick,  resisting  wall  of  the 
uterus  will  not  permit  of  so  sharp  bending  as  to  obstruct  the  passage 
of  spermatozoa.  Reasoning  a  priori,  an  extreme  retroversion  with 
the  cervix  pointing  upward  and  forward  would  more  likely  cause 
sterility  than  would  an  uncomplicated  retroflexion  with  the  cervix 


ETIOLOGY  71 

pointing  downward  and  backward.  From  like  reasoning,  descent  of 
the  uterus,  especially  when  associated  with  elongation  of  the  cervix, 
as  is  usually  the  case,  would  be  still  more  likely  to  result  in  sterility 
because  of  the  difficulty  of  the  semen  in  gaining  entrance  to  the 
cervical  canal. 

Traumatisms. — Traumatisms  to  the  cervix  and  vagina  not  infre- 
quently predispose  to  sterility.  A  lacerated  perineum  allows  of  the 
free  escape  of  semen  from  the  vagina,  and  a  lacerated  cervix,  followed 
by  erosion  and  eversion  of  the  cervical  mucous  membrane,  may  offer 
an  obstruction  to  the  semen.  Rectovaginal  and  vesicovaginal  fistulse 
cause  sterility  by  the  effect  of  the  urine  and  feces  upon  the  semen,  by 
the  accompanying  vaginitis  and  the  resulting  dyspareunia.  Cicatricial 
contraction  of  the  vagina  following  an  injury  may  interfere  with 
sexual  union. 

Pelvic  Inflammation. — Pelvic  inflammation  is  by  far  the  most  prolific 
source  of  sterility,  and  first  among  the  various  lesions  is  endometritis. 
The  hyperplastic  form  of  endometritis  will  most  certainly  cause  sterility, 
and  particularly  when  associated  with  profuse  hemorrhages  and  leucor- 
rhea.  The  diseased  endometrium  is  an  unfavorable  resting-place  for 
the  ovum,  and  the  discharges  play  havoc  with  the  spermatozoa.  In 
the  cervix  the  increased  mucous  secretions  of  endocervicitis  plug  the 
cervical  canal  so  effectually  as  to  prevent  the  entrance  of  the  semen. 
Vulvovaginitis  may  prevent  conception  through  perverted  acid  secretions 
and  dyspareunia.  Infections  of  the  tubes  destroy  the  cilia  and  often 
the  epithelium  as  well,  thereby  hindering  the  progress  of  the  ovum 
through  the  tube  to  the  uterus.  Closure  of  the  fimbriated  end  of  both 
tubes,  resulting  in  a  distention  of  the  tube  with  serum,  blood,  or  pus, 
will  almost  certainly  cause  permanent  sterility.  Yet  it  is  of  interest 
to  know  that  pregnancy  has  followed  upon  the  disappearance  of 
double  pyosalpinx,  a  fact  which  speaks  for  conservative  treatment 
of  salpingitis. 

A  chronic  inflammation  or  passive  congestion  of  the  ovary  results 
in  a  hyperplasia  of  the  connective  tissue  surrounding  the  follicles,  in 
a  thickening  of  the  tunica  albuginea,  and  in  possible  adhesions  about 
the  ovary.  All  this  renders  difficult  or  impossible  the  escape  of  ova 
into  the  tube. 

In  pelvic  cellulitis  and  pelvic  peritonitis,  constricting  bands  of  adhe- 
sions may  obstruct  the  lumen  of  the  tube,  and  so  displace  the  uterus, 
ovaries,  and  tubes  as  to  cause  sterility.  An  organized  exudate  about 
the  ovary  will  prevent  the  ova  escaping  and  lead  to  cystic  degeneration 
of  the  ovary.  In  all  these  forms  of  infection,  dyspareunia  is  a  large 
factor  in  the  causation  of  sterility. 

Neio-formations. — New-formations  as  causes  of  sterility  are  yet  to  be 
considered.  In  general,  they  operate  through  mechanical  obstruction. 
By  their  presence  an  inflammatory  reaction  may  develop  as  the  prime 
cause  of  the  sterility.  Degeneration  of  the  tumor  leading  to  an  irritating 
discharge  acts  in  a  deleterious  manner  upon  the  spermatozoa.  The 
size  of  the  groT\i;h  is  not  of  so  much  consequence  as  the  position;  a 


72  STERILITY 

small  fibroid  in  the  ce^^'ical  canal  may  cause  complete  obstruction, 
while  pregnancy  may  go  on  to  full  term  in  subperitoneal  fibroids  of 
enormous  size.  Malignant  growths  rarely  cause  sterility,  because  the 
childbearing  period  is  usually  at  an  end  before  the  advent  of  either 
carcinoma  or  sarcoma.  Sterility  associated  with  amenorrhea  in  the 
presence  of  an  ovarian  cyst  suggests  the  possible  presence  of  a  similar 
involvement  of  the  other  ovary. 

Venereal  Diseases. — Gonorrheal  infection  is  a  potent  cause  of 
sterility,  but  it  is  doubtful  whether  syphilis  is  often  a  cause  of 
absolute  sterility.     (See  chapter  on  Gonorrhea  in  Women). 

Treatment. — A  long  list  of  general  and  local  conditions  conduces  to 
sterility,  and  hence  the  treatment  of  sterility  becomes  equally  varied. 
Having  by  examination  excluded  the  existence  of  sterility  in  the  husband 
and  having  recognized  the  existence  of  a  lesion  which  in  itself  is  a  satis- 
factory explanation  for  the  existing  sterility  in  the  wife,  it  is  never 
safe  to  assure  the  patient  that  its  correction  will  permit  of  conception 
and  childbearing,  for  the  reason  that  there  are  so  many  associated 
conditions  which  may  enter  into  the  problem  and  preclude  the  possibility 
of  childbearing.  The  most  the  physician  can  say  is  that  if  a  given 
cause  or  group  of  causes  of  sterility  are  found  to  exist,  removal  will 
afford  greater  opportunity  for  childbearing.  When  upon  examination 
no  demonstrable  cause  for  sterility  is  found  and  the  husband  is  known 
to  be  potent,  an  exploratory  abdominal  incision  may  be  justified  in 
view  of  the  possible  finding  of  an  unrecognized  lesion,  such  as  the 
matting  of  the  fimbriae  and  so-called  "sclerosed  ovaries"  (interstitial 
ovaritis). 

Primary  sterility  is  not  infrequently  chargeable  to  an  underdevelop- 
ment of  the  genital  organs.  There  is  little  encouragement  from  any 
treatment,  though  Bumm  makes  claims  for  the  galvanic  current.  The 
negative  electrode  is  placed  in  the  uterus  and  the  positive  on  the  abdo- 
men. A  current  not  greater  than  50  milliamperes  is  used  and  for  a  time 
not  to  exceed  five  minutes.  This  treatment  is  given  twice  weekly. 
.  Dyspareunia  as  a  cause  of  sterility  demands  serious  consideration 
and  is  often  amenable  to  treatment.  When  there  is  no  evident  lesion 
to  account  for  an  existing  vaginismus,  an  anesthetic  should  be  given 
and  the  vulvar  outlet  and  vagina  thoroughly  stretched.  Sensitive 
carunculse  myrtiformes  may  be  the  cause  of  dyspareunia;  these  may  be 
cauterized  or  excised.  Urethral  caruncle  through  its  great  sensitiveness 
may  be  the  cause  of  dyspareunia  and  should  be  cauterized  or  excised. 

When  a  vulvovaginitis  or  an  inflammation  of  the  organs  and  tissues 
of  the  pelvis  exist,  long-continued  antiseptic  douches,  together  with 
glycerin  and  ichthyol  tampons,  may  be  used  with  eftect.  Here  operative 
measures  may  be  resorted  to  for  relief  from  an  infected  uterus  and  its 
appendages  and  from  peritoneal  adhesions.  When  the  appendages  are 
partially  or  wholly  occluded,  and  when  they  are  more  or  less  involved 
in  adhesions,  there  is  little  encouragement  derived  from  any  course  of 
treatment  so  far  as  concerns  sterility. 

In  endocervicitis,  when  the  cervical  canal  is  plugged  with  mucus. 


THE  MENOPAUSE  73 

the  author  has  known  of  relief  from  sterility  by  the  swabbing  of  the 
cervical  canal  and  the  application  of  mild  antiseptics.  Cervical  polj^ps 
as  a  potent  cause  of  sterility  demand  removal. 

For  a  discussion  of  the  treatment  of  uterine  displacements  and  new- 
formations  in  their  relation  to  sterility,  see  Chapter  III. 

Lacerations  of  the  cervix,  when  extensive  and  when  accompanied  by 
eversion  and  erosions,  should  be  repaired  and  the  pelvic  floor  restored 
when  greatly  relaxed  and  torn.  An  elongated  cervix  may  be  the  cause 
of  sterility  and  should  be  amputated. 

If  hj-peracidity  of  the  secretions  in  the  vagina  exists,  2  drams  of 
the  bicarbonate  of  soda  may  be  given  in  a  quart  of  water  at  a  temperature 
of  110°  F.  This  douche  should  precede  intercourse  to  prevent  the 
destruction  of  the  spermatozoa  by  the  acid  secretions. 

Inasmuch  as  it  is  impossible  to  say  that  the  endometrium  is  healthy, 
obscure  cases  of  sterility  are  often  relieved  by  an  exploratory  curettage. 

The  practice  of  artificial  insemination  has  been  practised  to  a  limited 
extent.    While  successful  in  a  few  cases  it  will  never  find  general  favor. 


THE  MENOPAUSE 


Premature  Menopause 
Delayed  Menopause 
Time  of  Appearance 
Clinical  Manifestations 


Influence   on   Morbid   Conditions 

'  IN  the  Pelvis 

Management 


The  menopause  is  a  perfectly'  natural  event  in  the  advanced  years 
of  women,  and  is  therefore  not  a  cause  of  ill  health.  The  popular  idea 
that  the  "change  of  life"  is  a  critical  time  in  a  woman's  life-history  is 
quite  correct,  but  this  does  not  imply  that  the  menopause  per  se  is  in 
any  way  a  menace  to  the  life  of  a  woman.  It  is  a  critical  time  because 
the  menopause  marks  the  beginning  of  old  age,  when  ill  health  and 
debility  would  naturally  be  first  manifest.  There  are,  however,  certain 
attending  phenomena  which  disturb  the  comfort  and  general  activity 
of  previously  healthy  women.  This  discomfort  is  not  ill  health;  that 
is  to  say,  it  is  not  to  be  dignified  by  the  term  disease.  There  is  a  dis- 
inclination to  mental  and  physical  exertion.  The  nervous  and  vascular 
systems  are  more  or  less  disturbed.  Functional  heart  troubles,  asso- 
ciated with  forebodings  of  impending  danger,  are  common  experiences. 
Hot  flashes,  a  sense  of  fulness  in  the  head,  and  drowsiness  are  com- 
plained of.  The  memory  fails  from  lack  of  concentration,  and  there 
is  a  marked  decline  in  the  capacity  for  both  mental  and  physical  work. 

These  are  the  usual  experiences  of  healthy  women  living  under 
favorable  circumstances  as  they  pass  through  the  menopause. 

Premature  Menopause. — The  menstrual  flow  may  be  permanently 
checked  at  an  early  age,  even  so  early  as  the  twenty-fourth  year.  The 
causes  of  premature  menopause  are  both  general  and  local.  The  general 
causes  are  those  referable  to  the  disorders  of  the  nutritive  and  vascular 


74  THE  MENOPAUSE 

systems — i.  e.,  primary  and  secondary  anemias  and  general  wasting 
diseases.  Fright  and  sorrow  are  said  to  precipitate  an  early  menopause. 
The  local  causes  include  the  remo^•al  of  the  menstrual  organs,  also 
infections,  degenerations,  and  new-formations  of  the  uterus  and 
ovaries.  It  is  interesting  to  observe  that  when  healthy  o^-aries  have 
been  removed,  thereby  bringing  on  the  menopause  abruptly,  the  usual 
derangements  of  the  climacterium  are  exaggerated;  whereas  the  removal 
of  ovaries  whose  functions  have  been  largely  lost  through  disease  causes 
little  or  no  disturbance. 

The  author  has  observed  a  woman,  aged  twenty  years,  who  had  not 
menstruated  for  two  years.  She  had  never  suffered  ill  health,  had  no 
evidence  of  a  pelvic  infection  or  other  lesion,  and  up  to  her  nineteenth 
year  had  menstruated  every  twenty-eight  days,  and  the  amount  of  the 
menstrual  flow  had  not  varied  from  the  normal,  kt  nineteen  she  stopped 
menstruating  and  the  periods  have  not  reappeared  in  the  succeeding 
two  years.  On  examination  the  uterus  was  about  two-thirds  the  normal 
size  of  a  matured  multiparous  uterus — otherwise  the  pelvic  organs 
appeared  normal. 

Delayed  Menopause. — The  menstrual  periods  may  be  continued 
far  beyond  the  a^•erage  time  and  without  anxiety  when  the  menstrual 
functions  appear  normal.  When,  however,  the  menses  become  increased 
in  frequency  and  in  amount  it  becomes  imperative  to  inquire  into  the 
cause.  The  general  and  local  causes  of  prolonged,  morbid  menstrual 
functions  are  enumerated  in  the  section  on  Uterine  Hemorrhage. 
Scanzoni  believes  that  the  prolonged  menopause  is  often  due  to  senile 
rigidity  and  friability  of  the  uterine  arteries,  while  Kisch  ascribes 
them  to  softening  and  relaxation  of  the  uterine  tissues.  Undoubtedly 
passive  congestion  of  the  pelvis  from  whatever  cause  may  prolong  the 
menstrual  period. 

In  the  absence  of  all  general  and  local  causes  for  hemorrhage  from 
the  uterus  it  is  possible  to  explain  the  prolonged  menopause  b}'  the 
existence  of  vasomotor  changes.  Care  must  be  taken  to  exclude  the 
presence  of  carcinoma  and  all  local  lesions  as  well  as  the  mentioned 
general  factors  before  accepting  such  indefinite  explanations  as  vaso- 
motor changes. 

Time  of  Appearance.— The  average  time  of  appearance  of  the 
change  of  life  is  from  forty  to  fifty-five  years  of  age.  Scanzoni  affirmed 
that  any  menstruation  after  fifty-three  years  of  age  should  be  regarded 
as  pathological.  Instances  are  not  rare  in  which  the  menopause  was 
recorded  as  not  reached  until  sixty  or  more  years  of  age.  Tilt  recorded 
one  at  seventy  years  of  age.  Currier  ten  at  sixty  to  ninety-three  years, 
and  that  of  a  nun  is  recorded  at  one  hundred  years  of  age.  Pregnancy 
is  known  to  occur  after  the  establishment  of  the  menopause.  '  Piron 
records  an  abortion  at  the  age  of  seventy-three.  The  factors  influencing 
the  time  of  appearance  of  the  menopause  are : 

Climate. — The  colder  the  climate  the  later  the  menopause. 

Social  State. — Sir  Andrew  Clark  states  that  the  menopause  occurs 
earlier  in  the  more  civilized  and  cultured  classes. 


CLINICAL  MANIFESTATIONS  75 

Race. — The  Jews  are  said  to  reach  the  menopause  at  an  earher  time 
than  the  average  woman  of  other  races  in  the  same  chmate. 

Heredity. — It  has  been  frequently  observed  that  heredity  has  a 
determining  influence  upon  the  establishment  of  the  menopause;  this 
tendency  toward  an  early  or  late  menopause  may  persist  through 
several  generations. 

General  and  Local  Diseases. — (a)  Those  favoring  an  early  climacterium 
are:  atrophy  of  the  uterus  and  ovaries,  superinvolution  of  the  uterus, 
chronic  atrophic  metritis  and  ovaritis,  postpartum  hemorrhages, 
puerperal  sepsis,  and  the  general  wasting  diseases,  (h)  Those  favoring 
a  late  climacterium  are:  malignant  growths  and  fibroids  of  the  uterus, 
endometritis,  subinvolution  of  the  uterus,  and  chronic  metritis. 

The  climacterium  has  an  average  duration  of  three  or  four  years,  and 
has  been  known  to  extend  over  a  period  of  twelve  years.  During  this 
time  the  menstrual  periods  commonly  recur  at  longer  and  longer 
intervals  as  the  flow  becomes  more  and  more  scant;  this  is  known  as 
the  "dodging  period." 

In  about  one  woman  in  seven  the  menses  stop  suddenly  and  per- 
manently. As  a  rule,  it  may  be  stated  that  an  abrupt  ending  of  the 
menstrual  periods  is  due  to  some  morbid  condition,  general  or  local. 

Clinical  Manifestations. — The  clinical  manifestations  of  the  meno- 
pause are  most  varied.  They  are  seldom  wholly  absent,  nor  are  they 
constantly  present.    As  a  rule,  they  recur  at  irregular  intervals. 

The  general  phenomena  associated  with  the  menopause  are  nervous 
disturbances,  such  as  irritable  temperament,  despondency,  forgetfulness, 
fainting,  vertigo,  flashes  of  heat  and  cold,  perversion  of  taste,  loss  of 
sexual  desire,  and  occasionally  a  homicidal  or  suicidal  tendency. 

The  local  phenomena  are  atrophy  of  the  genital  organs  and  of  the 
breasts,  and  in  many  cases  an  increase  in  the  body  weight. 

Under  normal  conditions  the  onset  of  the  menopause  is  marked  by 
the  beginning  of  a  retrograde  metamorphosis  in  the  ovaries,  tubes, 
uterus,  vagina  and  vulva,  and,  as  a  rule,  these  changes  occur  in  the 
order  named,  i.  e.,  from  above  downward  throughout  the  genital  tract. 
The  ovaries  present  a  progressive  thinning  of  the  cortical  zone;  a  gradual 
disappearance  of  ova  and  follicles  until  finally  the  ovary  is  shrunken 
into  little  more  than  a  fibrous  nodule.  The  Fallopian  tubes  lose  their 
ciliated  epithelium,  the  lumen  is  obliterated,  and  finally  the  tubes  are 
converted  into  mere  cords.  The  uterus  becomes  smaller  in  all  dimen- 
sions, the  uterine  canal  becomes  distorted,  the  myometrium  thins 
through  atrophy  and  disappearance  of  the  muscle  fibers,  the  vaginal 
portion  of  the  cervix  is  no  longer  in  evidence,  and  the  body  of  the  uterus 
is  finally  resolved  to  a  fibrous  ridge  or  nodule.  The  vaginal  walls  become 
pale,  dry,  and  glistening.  Contraction  is  greatest  at  its  upper  portion, 
thereby  forming  an  irregular  funnel-shaped  cavity.  The  external 
genitals  lose  their  pad  of  subcutaneous  fat,  the  hair  becomes  gray,  and 
there  is  a  general  flattening  and  shrinking  of  the  vulva. 

There  are  no  facts  to  substantiate  the  statement  that  the  develop- 
ment of  skin  diseases  is  influenced  by  the  menopause. 


76  THE  MENOPAUSE 

Influence  on  Morbid  Conditions  in  the  Pelvis. — It  will  be  of  prac- 
tical interest  to  inquire  into  the  influence  of  the  menopause  upon  certain 
morbid  conditions  in  the  pelvis.  A  certain  percentage  of  these  lesions 
arises  during  the  climacterium,  while  others  are  aggravated  or  are  made 
to  disappear  by  the  advent  of  the  change  of  life. 

Foremost  among  the  lesions  that  are  prone  to  appear  in  the  climac- 
terium are  malignant  groT\-ths.  Peculiar  catarrhal  forms  of  endometritis 
are  known  to  arise  at  this  time.  Displacements  of  the  uterus,  and  par- 
ticularly prolapsus  uteri,  are  of  common  occurrence  as  the  result  of 
retrograde  metamorphosis  of  the  uterine  supports.  Fibrous  polyps  of 
the  cervix  are  said  to  frequently  arise  subsequent  to  and  during  the 
climacterium  and  are  the  cause  of  hemorrhage — a  fact  which  the 
author's  experience  confirms. 

Existing  conditions  in  the  pelvis  which  are  aggravated  by  the  meno- 
pause are  displacements  of  the  uterus  due  to  relaxation  of  the  uterine 
supports.  A  descensus  may  become  converted  into  a  complete  pro- 
lapsus as  the  uterine  supports  relax  after  the  menopause. 

On  the  other  hand  the  menstrual  disturbances  and  pressure  s}Tap- 
toms  incident  to  displacements  of  the  uterus  and  its  appendages  are 
relieved  by  the  suspension  of  menstruation  and  diminution  in  the  size 
of  the  uterus.  Fibroids  of  the  uterus  very  often  cease  to  grow,  and  not 
infrequently  decrease  in  size.  This  is  particularly  true  of  interstitial 
fibroids.  While  favorable  changes  in  uterine  fibroids  may  be  hoped  for 
at  the  climacterium,  it  must  be  remembered  that  the  fibroid  may  be 
transformed  into  a  sarcoma  or  into  other  forms  of  degeneration  which 
may  jeopardize  life.  The  influence  of  the  menopause  upon  existing 
ovarian  cysts  is  not  clearly  understood.  The  statistics  of  Olshausen 
and  others  show  that  cysts  of  the  ovary  arise  more  often  during  the 
period  of  sexual  maturity  and  far  less  frequently  after  the  climacterium. 
The  "involuted  shrunken  cysts"  of  Rokitansky  are  often  the  direct 
result  of  the  menopause,  though  perhaps  they  more  often  follow  upon 
the  twisting  of  the  pedicle.  Fatty  degeneration  of  the  cyst  wall  is 
especially  prone  to  occur  during  and  after  the  menopause,  and  this 
suggests  the  most  probable  cause  of  spontaneous  rupture  of  ovarian 
cysts  at  this  time. 

Management  of  the  Menopause. — Every  woman  passing  through 
the  menopause  should  be  under  the  guidance  of  a  physician.  This 
does  not  imply  that  she  is  necessarily  in  a  critical  condition,  but  the 
discomforts  which  invariably  accompany  the  menopause  can  be  lessened 
by  judicious  management.  Furthermore,  it  is  at  this  time  when  many 
of  the  infirmities  of  old  age  are  initiated,  and  if  recognized  in  their 
incipiency  they  may  be  forestalled. 

It  is  a  deplorable  fact  that  women  in  general  regard  the  menbpause 
as  a  time  of  all  sorts  of  serious  events,  and  as  a  result  of  this  popular 
impression,  many  serious  conditions  arising  at  this  time  are  ascribed  to 
the  menopause;  they  are  regarded  as  inevitable  afilictions.  They  look 
forward  to  the  establishment  of  the  climacterium,  when  they  wdU  find 
relief,  and  thus  they  are  deceived  into  serious  and  even  fatal  conditions. 


MANAGEMENT  OF  THE  MENOPAUSE  77 

Uterine  hemorrhages  and  leucorrheal  discharges  are  interpreted  as  a  part 
of  the  usual  workings  of  the  menopause,  and  in  this  delusion  the  patient 
becomes  the  victim  of  an  inoperable  malignant  groivth. 

It  is  of  the  utmost  importance  to  look  to  the  general  state  of  health 
at  this  time.  Medicine  is  of  secondary  importance,  but  fresh  air,  the 
judicious  regulation  of  rest  hours  and  open-air  exercises,  the  selection 
of  the  diet,  the  regulation  of  the  bowels  and  secretions,  the  employment 
of  suitable  baths,  all  are  of  prime  importance.  This  is  the  fretful  period 
of  life,  and  as  such  the  women  who  are  passing  through  this  trying 
period  should  be  safeguarded  as  far  as  possible  from  petty  annoyances, 
and  should  be  placed  in  an  environment  most  suited  to  their  tempera- 
ment. They  should  be  consulted  as  to  their  desires  and  should  be 
gratified  within  all  reasonable  bounds.  It  may  be  advisable  to  recom- 
mend travel  or  some  health  resort  or  sanitarium. 

Thyroid  Extract. — Thyroid  extract  has  been  extolled  as  a  useful  remedy 
in  controlling  the  nervous  symptoms  associated  with  the  menopause. 
In  the  author's  hands  there  have  been  indifferent  results  in  the  admin- 
istration of  thyroid  extract,  and  he  believes  this  to  be  the  experience 
of  most  clinicians. 

Corpus  Luteum  Extract. — Corpus  luteum  extract  is  prepared  in  5- 
grain  capsules.  It  is  a  valuable  remedy  in  controlling  the  disturbances 
incident  to  the  removal  of  the  ovaries,  especially  if  given  shortly  after 
the  operation  and  persisted  in  for  several  months  in  doses  of  5  grains 
three  or  four  times  a  day.  The  author  has  had  most  gratifying  residts 
in  these  cases  and  never  fails  to  prescribe  it.  It  does  not  give  such 
positive  results  in  the  natural  menopause,  but  is  of  some  value  in  a 
limited  number  of  cases. 


CHAPTER   IV 

exa]\iixatiox  of  the  blood— bacteriological 
exa:^iixatiox 

EXAMINATION  OF  THE  BLOOD 

^Morphology  of  Blood  Cells  Lel-cocytosis 

Red  Cells  Differextl\l  Count  of  Leucocytes 

White  Cells  Axemia 

By  adopting  a  routine  practice  of  making  systematic  examinations 
of  the  blood  in  all  operative  cases,  the  diagnosis  has  often  been  made 
more  certain,  the  indications  for  operation  have  been  more  judiciously 
considered  (not  infrequently  an  operation  has  been  postponed  until 
the  conditions  of  the  blood  improved),  the  choice  of  the  anesthetic 
has  hinged  upon  the  blood  findings,  as  has  also  the  choice  of  operation, 
and  finally,  the  prognosis  has  been  influenced  by  repeated  examinations 
of  the  blood. 

In  routine  clinical  work  the  examinations  of  the  blood  are  of  no  less 
importance  than  the  analysis  of  the  urine.  In  a  large  percentage  of  cases 
no  additional  information  will  be  aflforded  by  examining  the  blood, 
but  in  those  cases  in  which  the  responsibility  is  the  greatest  these 
examinations  become  of  the  highest  value.  Without  a  blood  examina- 
tion the  writer  would  have  submitted  one  patient  with  17  per  cent, 
of  hemoglobin  to  an  operation  for  hemorrhoids,  and  another  patient 
with  20  per  cent,  of  hemoglobin  to  an  abdominal  hysterectomy  for 
uterine  fibroids.  In  all  probability  the  results  would  have  been  fatal 
from  what  is  called  surgical  shock.  Rest  in  bed  and  a  liberal  diet 
brought  the  former  case  up  to  35  per  cent,  and  the  latter  to  78  per 
cent,  before  the  operations  were  undertaken. 

It  is  well  known  how  misleading  mere  inspection  may  be  even  in 
making  an  approximate  estimate  of  the  degree  of  anemia.  A  blood 
examination  will  often  show  a  far  greater  degree  of  anemia  than  was 
suspected. 

Morphology  of  the  Blood  Cells. — Red  Cells. — These  cells  are  bicon- 
cave, disk-shaped  bodies  of  a  yellowish  color  in  the  fresh  state. 

Size. — The  diameter  of  the  red  cells  in  adults  averages  3  9^0  0  inch 
and  is  almost  constant  within  normal  limits.  In  the  marked  anemias 
the  diameter  is  more  or  less  altered.  There  is  little  or  no  alteration 
in  the  mild  forms  of  anemia. 

L  ]\Iicrocytes  are  not  found  in  normal  blood.  In  severe  t\'pes 
of  anemia  small  red  cells,  known  as  microcytes,  are  found  in  varying 
numbers.    This  is  especially  true  of  pernicious  anemia. 


MORPHOLOGY  OF  THE  BLOOD   CELLS  79 

2.  Megalocytes  are  large  red  cells.  They  may  be  two  and  one-half 
times  the  average  size  of  red  cells.  They  indicate  a  chronic  anemia 
of  severe  grade. 

Shape. — Normal  red  cells  are  biconcave  disks,  but  under  certain 
impoverished  conditions  of  the  blood  the  margins  present  a  serrated 
appearance   (poikilocytes). 

Average  Number. — The  average  number  of  red  cells  is  4,500,000  to 
5,000,000  to  the  cubic  millimeter.  This  number  shows  great  variation 
in  the  various  forms  of  blood  diseases. 

Nucleated  Red  Cells. — Nucleated  red  cells  are  never  found  in 
adults  under  normal  conditions. 

1.  Normoblasts  do  not  differ  in  size  from  normal  red  cells,  but 
contain  a  nucleus  which  occupies  about  one-third  of  the  cell.  They 
stain  deeply  and  do  not  form  rouleaux.  In  the  absence  of  megalo- 
blasts  they  usually  indicate  a  mild  t^pe  of  primary  or  secondary  anemia. 

2.  ^Nlegaloblasts  are  larger  than  the  normal  red  cells  and  contain 
a  large  nucleus.  Taken  alone  they  certainly  suggest  a  morbid  state  of 
the  blood,  but  their  exact  significance  is  implied  by  the  associated  red 
cells.  They  are  of  greatest  significance  in  pernicious  anemia,  in  which 
they  are  found  in  large  numbers,  though  the  diagnosis  max  be  made 
from  the  finding  of  a  single  megaloblast. 

AMorNT  OF  Hemoglobix. — It  is  of  the  utmost  importance  to  estimate 
the  relative  amount  of  hemoglobin.  The  various  anemias  show  great 
variations  in  this  respect. 

White  Cells  (Leucocytes). — ^Iokphology. — Leucocytes  are  colorless 
bodies,  varying  in  size  and  numbers  of  contained  nuclei.  As  a  rule 
they  are  larger  than  red  cells.    They  possess  ameboid  movements. 

Five  varieties  are  recognized: 

Lymphocytes. — Lymphocytes  are  both  small  and  large.  They  have 
a  round  nucleus  surrounded  by  a  narrow  rim  of  homogenous  or  reticu- 
lated protoplasm. 

Large  Mononuclear  Leucocytes. — They  possess  a  coarsely  reticular, 
vesicular  nucleus  surrounded  by  finely  reticular  protoplasm.  The 
nuclei  may  be  round,  horseshoe-shape,  or  elongated.  The  cell  body 
is  usually  much  larger  than  a  lymphocyte. 

Polynuclear  Leucocytes. —  Polynuclear  leucocytes  are  larger  than 
mononuclear  leucocytes.  Neutrophile  granules  are  found  in  the  reticu- 
lar protoplasm.  The  nuclei  are  elongated  and  may  be  connected  by 
threads  of  chromatin.  * 

Eosinophile  Leucocytes. — Large  granules  are  found  in  the  protoplasm 
and  take  a  deep  eosin  stain.  The  nuclei  are  usually  bilobed.  In  size 
the  cell  is  seldom  so  large  as  a  polynuclear  leucocyte. 

Mast-cells. — Mast-cells  contain  large  and  small  basophile  granules. 
They  vary  in  size  and  in  number  of  nuclei. 

Number  of  Leucocytes. — The  number  of  leucocytes  in  a  cubic 
millimeter  may  be  said  to  vary  from  7000  to  10,000  within  physiological 
limits.  The  number  of  leucocytes  is  notably  increased  in  the  newborn, 
during  pregnancy,  after  ingestion  of  food,  and  after  active  exercise. 


80  EXAMIXATION  OF   THE  BLOOD 

Leucocj^osis. — An  increase  in  the  number  of  leucocytes  above  that 
of  the  normal,  for  the  particular  individual  under  definite  conditions, 
is  known  as  leucocytosis.  For  one  individual  3000  leucocytes  per 
cubic  millimeter  may  be  normal,  while  for  another  of  greater  vigor 
10,000  may  not  exceed  the  normal  limits.  x\gain,  a  blood-count  taken 
shortly  after  a  full  meal  or  during  pregnancy  would  naturally  show 
an  excess  of  leucocytes  as  compared  with  other  physiological  conditions. 
For  purposes  of  comparison  the  leucocyte-count  should  be  taken  at 
regular  intervals;  these  counts  are  best  taken  three  or  four  hours  after 
eating. 

In  leucocytosis  it  is  not  only  essential  to  know  the  number  of  leuco- 
cytes, but  when  the  number  is  greatly  in  excess  of  the  normal  (25,000 
to  80,000  to  the  cubic  millimeter)  it  is  also  essential  to  make  a  differential 
count  in  order  to  distinguish  a  true  splenic,  myelogenous,  or  lymphatic 
leukeibia  from  a  leucocytosis  incident  to  suppuration,  pneumonia, 
malignancy,  and  other  morbid  conditions.  In  the  practice  of  gynecology 
and  obstetrics  it  is  seldom  necessary  to  resort  to  a  differential  count; 
but  it  may  be  stated  as  a  safe  rule  to  follow  that  when  the  white 
cell  count  exceeds  25,000  to  the  cubic  millimeter  a  differential  count 
should  be  made.  This  rule  becomes  imperative  when  the  local  findings 
do  not  suggest  suppuration,  pneumonia,  or  malignancy,  and  when  the 
general  anemia  or  enlarged  spleen  justifies  the  suspicion  of  a  primary 
anemia.  By  the  aid  of  a  leucocyte  count  it  becomes  possible  to  say  not 
only  that  the  individual  is  sick,  but  also  to  estimate,  to  a  certain  extent, 
the  degree  of  illness,  and  thereby  to  formulate  a  more  definite  prognosis. 

Leucocytosis  of  Pregnancy. — In  the  early  weeks  of  pregnancy  there 
is  little  increase  in  the  number  of  leucocytes,  but  in  the  latter  half  the 
number  averages  about  10,000  to  the  cubic  millimeter  in  primiparee. 
It  is  observed  that  leucocytosis  is  not  so  constant  in  multiparse — • 
probably  not  more  than  50  per  cent,  show  an  average  of  10,000.  Near 
the  time  of  labor  the  physiological  limit  may  exceed  18,000.  Cabot 
found  a  leucocyte  count  of  25,000  to  37,000  in  three  normal  pregnancies. 
Since  no  leucocytosis  is  expected  before  the  end  of  the  third  month, 
a  blood  examination  will  aid  but  little  in  the  diagnosis  of  pregnancy. 
In  the  later  months  of  pregnancy,  when  the  question  is  raised  as  to 
the  differential  diagnosis  of  pregnancy  from  other  pelvic  and  abdominal 
swellings,  leucocytosis  will  give  little  clue  because  in  almost  all  of  these 
conditions  it  is  expected  that  the  leucocyte  count  will  be  high. 

Postpartum  Leucocytosis. — After  childbirth,  when  conditions  are 
perfectly  normal,  the  number  of  white  cells  gradually  diminishes  and 
usually  returns  to  that  of  the  non-pregnant  state  in  about  two  weeks. 
When  much  blood  has  been  lost,  or  when  there  have  been  excessive 
lacerations  or  infection  in  the  pelvis  or  breast,  the  usual  diminution  in 
white  cells  is  interrupted.  After-pains  are  said  to  retard  the  gradual 
diminution  of  the  leucocytes. 

Pathological  Leucocytosis. — Posthemorrhagic  Leucocytosis. — By  experi- 
mental and  clinical  observations  it  is  known  that  immediately  after  a 
severe  acute  hemorrhage  there  is  an  initial  diminution  in  the  number 


LEUCOCYTOSIS  81 

of  leiicoc}-tes.  Very  soon  a  rapid  increase  in  the  number  of  white 
cells  takes  place.  Within  a  few  hours  this  leucoc\i;osis  may  reach 
45,000,  and  it  has  been  known  to  go  as  high  as  62,000.  In  three  or  four 
days  the  leucocytosis  gradually  recedes,  but  seldom  returns  to  the  normal 
in  less  than  a  month.  Leucocytosis  is  usually  proportionate  to  the 
amount  of  blood  lost  and  to  the  acuteness  of  the  attack.  Xo  such 
condition  is  observed  in  chronic  hemorrhages.  The  author  has  failed 
to  observe  leucocytosis  in  large  but  long-standing  collections  of  blood 
in  the  pelvis  from  ruptured  tubal  pregnancy. 

The  increase  in  the  number  of  leucoc\i:es  immediatelv  following 
upon  a  postpartum  hemorrhage  is  great  m  proportion  to  the  amount 
of  blood  lost.  This  is  due  to  the  contributing  influence  of  pregnancy, 
which  in  itself  causes  leucocytosis  to  a  variable  degree.  The  leucocytosis 
disappears  long  before  the  number  of  red  cells  returns  to  the  normal. 
It  is  difficult  to  explain  the  absence  of  leucocytosis  in  occasional  cases 
of  acute  hemorrhages;  the  explanation  probably  lies  in  the  lowered 
resistance  of  the  individual. 

Inflammatory  Leucocytosis. — It  is  a  rule,  to  which  there  are  few 
exceptions,  that  the  number  of  white  cells  is  increased  above  the  phy- 
siological limit  in  septic  infections,  whether  localized  or  general.  This 
leucocytosis  is  proportionate  to  the  virulence  of  the  infection  and  to 
the  resistance  of  the  individual — not  to  the  amount  of  exudate.  A  large 
pelvic  abscess  of  long  standing,  containing  no  virulent  microorganisms 
and  weH  walled  oft'  by  firm  adhesions,  very  frequently  causes  no  leuco- 
cytosis. The  greater  the  resistance  of  the  individual  the  greater  will 
be  the  leucocytosis.  That  is  to  say,  an  individual  with  poor  resistance 
and  a  virulent  infection,  may  have  no  greater  leucocytosis  than  an 
individual  with  high  tissue  resistance  and  a  less  virulent  infection.  It 
is  observed  that  so  long  as  the  shock  of  an  operation  lasts,  leucocytosis 
does  not  appear,  but  just  in  proportion  to  the  reaction  of  the  patient 
from  shock  there  is  a  development  of  leucocytosis,  showing  that  with- 
out reaction  of  the  tissues  leucocytosis  will  not  occur.  A  purulent 
exudate  usually  produces  a  higher  degree  of  leucocytosis  than  does  a 
serous  exudate,  for  the  reason  that  the  infection  is  more  virulent.  While 
it  is  possible  for  a  fever  to  exist  without  an  increase  in  the  number  of 
white  cells,  it  is  true  that  when  the  fever  is  solely  dependent  upon  the 
infection,  the  leucocytosis  will  rise  and  fall  with  the  temperature. 
"When  the  individual  becomes  overwhelmed  with  sepsis  the  tissues 
fail  to  react,  and  hence  leucocytosis  fails  to  appear.  The  number  of 
white  cells  increases  in  proportion  to  the  reaction  of  the  patient  from 
the  septic  influences,  and  therefore  may  be  regarded  as  a  favorable 
omen  rather  than  as  evidence  of  increased  infection. 

In  a  large  number  of  observations  on  acute  and  subacute  cases  in  which 
pus  was  confined  to  the  tube,  ovary,  appendix,  broad  ligament,  or  cul- 
de-sac,  the  leucocj-tosis  usually  ranged  between  12,000  and  19,000,  the 
maximum  being  24,000.  In  long-standing  pus  tubes,  in  which  the  con- 
tents were  sterile,  the  number  of  leucocytes  did  not  exceed  the  normal. 
It  is  therefore  seen  that  leucocytosis  is  not  a  constant  factor  in  the 
6 


82  EXAMINATION  OF  THE  BLOOD 

presence  of  pus,  but  is  directly  proportionate  to  the  \'irulence  of  the 
infection  and  the  resistance  of  the  tissues.  The  white  count  is  therefore 
of  no  little  value  in  determining  the  virulence  of  infection.  In  the 
presence  of  pus  localized  in  the  pelvis  the  determination  of  an  accom- 
panying leucocytosis  will  lead  to  early  interference  and  will  at  least 
suggest  the  advisability  of  establishing  drainage  through  the  vagina 
rather  than  through  an  abdominal  incision. 

Tuberculous  pus  causes  no  leucocytosis,  and  gonorrheal  plis  only  a 
moderate  increase  in  the  number  of  leucocytes.  This  is  explained  on 
the  theory  of  greater  tolerance  and  less  power  of  absorption  of  the 
peritoneum  for  these  bacteria  and  their  toxins. 

Repeated  leucocyte  counts  are  of  special  value  when  taken  in  con- 
junction with  the  pulse  and  temperature.  By  combining  these  obser- 
vations it  is  possible  to  make  a  fairly  accurate  diagnosis  of  the  presence 
of  pus  and  to  judge  something  of  the  virulence  of  the  infection. 

In  pelvic  exudates,  leucocytosis  is  a  valuable  indication  for  operative 
interference;  the  more  chronic  the  case  the  greater  the  value.  In 
subacute  and  chronic  cases,  with  little  or  no  rise  in  temperature  and  a 
leucocytosis  of  12,000  to  18,000,  pus  is  almost  certainly  present. 

Leucocytosis  of  Malignancy. — In  general  it  is  said  that  the  blood 
changes  are  proportionate  to  the  degree  of  malignancy.  The  more 
rapid  the  growth  aiid  the  greater  the  metastasis  the  more  advanced 
the  leucocytosis.  In  cancer  of  the  uterus,  vagina,  and  vulva  the 
associated  hemorrhages  and  infections,  if  acute  and  great,  contribute  to 
the  leucocytosis.  The  resisting  power  of  the  individual  also  influences 
the  degree  of  leucocytosis.  The  effects  of  sarcoma  upon  the  blood  are 
of  the  same  sort,  but  are  said  to  be  of  a  greater  degree  than  in  car- 
cinoma. In  thirteen  of  the  author's  cases  of  malignancy  there  was  no 
leucocytosis  in  eight.  The  highest  white  count  was  16,000.  Blood 
examinations  will,  therefore,  aid  little  or  not  at  all  in  the  diagnosis  of 
malignancy. 

The  author  has  not  observed  that  leucocytosis  is  more  marked  in 
sarcoma  than  in  cancer;  in  the  two  cases  observed  the  white  count 
did  not  exceed  10,000. 

Leucocytosis  in  Ovarian  Tumors. — In  ovarian  tumors  there  may  be 
an  increase  in  the  leucocyte  count.  This  is  particularly  true  if  the 
pedicle  is  twisted  and  if  there  is  irritation  of  the  peritoneum.  The 
leucocyte  count  does  not  aid  in  determining  the  malignancy  of  an 
ovarian  tumor,  but  when  the  red  cells  are  diminished  there  is  a  sug- 
gestion of  possible  malignancy.. 

Differential  Count  of  Leucocytes. — Pus  may  be  present  in  the  absence 
of  any  increase  in  number  of  the  leucocytes.  Such  cases  will,  as  a  rule, 
show  an  increase  in  the  polymorphonuclear  leucocytes  to  ove'r  80  per 
cent.  In  certain  chronic  abscess  formations,  both  the  qualitative  and 
quantitative  estimates  m.ay  fail  to  suggest  the  presence  of  pus — these 
cases  are  exceptional. 

In  the  hands  of  an  expert  laboratory  worker  the  quantitative  count 
is  of  great  value  in  selected  cases,  but  for  the  ordinary  clinician  it  is 
of  little  or  no  value  because  of  its  technical  difficulties. 


ANEMIA  83 

Anemia. — It  is  of  the  greatest  importance  for  the  obstetrician  and 
gynecologist  to  accurately  diagnosticate  both  primary  and  secondary 
anemias.  Primary  and  secondary  anemias  are  not  infrequent  causes 
of  amenorrhea,  menorrhagia,  sterility,  and  abortion,  and  hence  the 
recognition  of  the  extent  and  variety  of  anemia  has  a  very  special 
value  in  diagnosis.  Too  often  the  physician  assumes  that  the  disorder 
is  a  local  one  when  in  reality  it  is  a  general  blood  affection.  It  becomes 
imperative  to  know  the  degree  of  anemia  before  resorting  to  a  major 
operation.  The  individual's  general  appearance  is  not  a  safe  guide. 
In  the  cases  already  referred  to,  the  one  with  20  per  cent,  of  hemo- 
globin and  the  other  with  17  per  cent,  did  not  appear  to  be  nearly  so 
anemic,  and  without  a  blood  examination,  would  have  been  operated 
without  knowledge  of  the  great  danger. 

When  the  history  points  to  a  primary  anemia  a  differential  blood 
count  must  be  made.  By  cover-slip  preparations  and  properly  selected 
stains,  chlorosis,  pernicious  anemia,  and  the  leukemias  are  recognized. 
This,  together  with  the  estimate  of  the  number  of  red  and  white  cells 
and  the  percentage  of  hemoglobin,  constitutes  an  exact  diagnosis. 

Secondary  Anemia. — Secondary  anemia  is  the  result  of  some  definite 
cause,  such  as  digestive  disturbances,  infection,  and  hemorrhage.  In 
the  mildest  forms  it  is  manifested  merely  by  diminution  in  the  size 
of  the  red  cells  and  a  corresponding  decrease  in  the  amount  of  hemo- 
globin. The  number  of  red  cells  may  not  be  lessened.  Again,  the  red 
cells  may  assume  irregular  shapes  and  sizes  (poikilocytes,  microcytes, 
macrocytes) . 

A  still  greater  degree  of  anemia  is  manifested  by  a  decrease  in  the 
number  of  red  cells  as  well-  as  by  alteration  in  their  shape  and  size. 
As  an  indication  of  the  most  advanced  type  of  secondary  anemia, 
there  are  added  to  the  alterations  in  the  shape  and  size  of  the  red 
cells  and  to  the  decrease  in  their  number,  certain  regenerative  changes 
in  the  red  cells.  Nucleated  red  cells  are  found — normoblasts,  micro- 
blasts,  megaloblasts.  During  the  preparation  of  this  chapter  the 
author  had  under  observation  a  seventeen-year-old  girl  who  had  but  10 
per  cent,  of  hemoglobin  and  1,200,000  red  cells  as  the  result  of  uterine 
hemorrhages  caused  by  a  fibroid  tumor.  In  high  degrees  of  anemia, 
where  operative  interference  is  indicated  for  relief  from  a  pelvic  dis- 
order, the  exact  degree  of  anemia  is  determined  before  resorting  to 
the  operation.  It  will  be  of  interest  to  inquire  as  to  the  degree  of  anemia 
which  would  contra-indicate  an  operation. 

Each  case  must  be  a  law  unto  itself.  There  are  many  things  to 
consider :  The  urgency  of  the  indication  for  operative  interference, 
which  may  be  very  great  in  septic  conditions  and  hemorrhage;  the 
general  condition  of  the  patient  excluding  the  anemia;  and  finally  the 
nature  of  the  operation,  particularly  as  to  the  duration  of  the  anesthesia 
required.  The  author  has  curetted  and  packed  the  uterus  under  chloro- 
form anesthesia,  where  there  was  only  20  per  cent,  of  hemoglobin;  this 
was  done  for  the  purpose  of  controlling  the  hemorrhage  until  the 
blood  could  be  built  up  to  a  point  that  would  justify  an  abdominal 


84  BA  CTERIOLOGICA  L  EX  A  MIX  A  TIOX 

hysterectomy  for  the  removal  of  a  uterhie  fibroid.  When  pus  can 
be  drained  through  the  vagina  or  the  uterus  curetted  for  the  relief  of 
hemorrhage  it  would  be  Avise  to  dispense  Avith  anesthesia,  when 
possible,  if  the  blood  is  very  low. 

In  general  it  may  be  said  that  there  should  be  no  protracted  operation 
with  the  hemoglobin  below  40  per  cent,  and  the  red  cell  count  less 
than  2,000,000.  There  are  exceptions  to  this  rule,  but  all  such  cases 
must  necessarilv  be  hazardous. 


BACTERIOLOGICAL  EXAIVQNATION 

Bacteriology  of  Normal   Genital  Bacteriology  of  Fallopian   Tubes 

Tract  Bacteriology  of  Ovary 

Bacteriology  of  Vulva  and  Vagina  Bacteriology  of  Peritoneum  and 

Bacteriology  of  Uterus  Pelvic  Cellular  Tissue 

While  the  range  of  bacteriology  in  diseases  of  women  is  comparatively 
limited,  the  value  of  bacteriological  examinations  in  selected  cases 
cannot  be  oA'erestimated.  By  these  examinations  it  is  possible  to 
arrive  at  the  diagnosis  of  the  essential  cause  of  the  infection  and  to 
determine  whether  the  pus  is  sterile  or  virulent,  and,  having  done 
so,  the  prognosis  is  made  with  more  certainty  and  the  method  of 
treatment  is  more  intelligently  decided  upon. 

The  pathogenic  organisms  commonly  found  in  the  genital  tract 
are  the  staphylococcus  pyogenes  albus  and  aureus,  streptococcus 
pyogenes,  gonococcus,  colon  bacillus,  tubercle  bacillus,  bacillus  lanceo- 
latus,  and  typhoid  bacillus.  Pathogenic  microorganisms  less  frequently 
found  in  the  genital  tract  are  the  bacillus  aerogenes  capsulatus, 
pneumococcus,  diphtheria  bacillus,  tetanus  bacillus,  bacillus  pyo- 
cyaneus,  anaerobic  putrefactive  bacteria,  streptococcus  of  erysipelas, 
and  the  streptothrix  actinomyces.  There  is  great  confusion  in  the 
literature  regarding  the  relative  frequency  with  which  these  organisms 
are  found.  Indeed,  it  is  not  possible  to  make  any  definite  statement 
as  to  their  relative  frequency. 

The  reader  is  referred  to  special  works  on  bacteriology  for  detailed 
descriptions  of  the  micro5rganisms  common  to  the  genital  tract.  The 
author  will  attempt  only  a  clinical  consideration  of  the  subject  from  a 
diagnostic  point  of  \ie\v. 

Bacteriology  of  the  Normal  Genital  Tract. — The  upper  genital  tract 
— i.  e.,  cervix,  uterine  body,  tubes,  and  ovaries — is  free  from  all 
forms  of  microorganisms  under  normal  conditions.  Much  difference  of 
opinion  exists  as  to  the  bacteriology  of  the  vagina  in  health.  That 
numerous  bacteria  are  found  in  the  healthy  A'agina  is  generally  recog- 
nized, but  to  what  extent,  if  any,  these  microorganisms  are  pathogenic 
is  an  unsettled  question.  Numerous  observations  have  been  made 
to  determine  this  question.  Kronig,  Menge,  and  Whitridge  Williams 
carefully  excluded  the  possibility  of  contamination,  and  agreed,  from 
extended  observations,  that  pathogenic  organisms  could  not  long  exist 


BACTERIOLOGY  OF  THE  VULVA  AND   VAGINA  85 

in  the  healthy  vagina.  Their  experiments  were  largely  carried  out 
during  pregnancy.  These  authors  ascribe  to  the  vaginal  secretion  an 
antiseptic  action  which  is  more  pronounced  during  pregnancy.  The 
vulva  is  rich  in  pathogenic  as  well  as  non-pathogenic  microorganisms. 
This  accounts  for  the  readiness  with  which  the  vagina  is  contaminated. 
It  is  of  interest  to  know  that  the  intact  vaginal  and  vulvar  surface 
will  not  admit  of  infection.  In  order  that  infection  of  these  surfaces 
be  possible,  there  must  be  an  atrium  for  infection  acquired  by  direct 
injury,  maceration  of  the  epithelium  from  profuse  irritating  secretions, 
the  development  of  malignant  growths,  or  lastly,  the  devitalization 
and  desquamation  of  the  epithelium  incident  to  old  age.  Not  so  with 
the  delicate  surface  epithelium  of  the  uterus  and  tubes.  Here  the 
infection  is  readily  engrafted  upon  the  healthy  surface.  Not  infre- 
quently an  infection  acquired  per  vaginam  will  primarily  attack  the 
endometrium  and  later  the  vaginal  surface  when  the  epithelial  covering 
has  been  macerated  by  the  uterine  secretion. 

Bacteriology  of  the  Vulva  and  Vagina. — Undoubtedly  various  patho- 
genic and  non-pathogenic  microorganisms  exist  from  time  to  time  in 
the  vulva  and  vagina.  That  they  do  not  more  frequently  cause  infec- 
tion is  due  to  the  fact  that  the  vulva  and  vagina  are  so  well  protected 
by  stratified  squamous  epithelium.  In  infancy  and  old  age,  when  the 
epithelium  has  not  the  resisting  power  found  in  mature  life,  the  vulva  and 
vagina  are  more  susceptible  to  infections  and  especially  to  gonorrhea. 
In  the  newborn  the  vagina  is  free  from  microorganisms,  but  a  variety 
of  germs  may  enter  soon  after  birth.  It  is  agreed  upon  by  all  observers 
that  pathogenic  bacteria  lose  their  virulence  as  they  approach  the 
cervix.  This  fact  is  due,  in  all  probability,  to  the  presence  of  lactic 
acid,  which  in  turn  is  the  product  of  an  acid-forming  microorganism 
discovered  by  Doderlein.  This  organism  offers  a  restraining  and  often 
a  prohibitive  influence  upon  pathogenic  organisms,  thereby  preventing 
the  infection  of  the  upper  genital  tract  unless  the  organisms  are  carried 
there  by  hands  and  instruments.  Certain  organisms,  particularly  the 
gonococcus  and  streptococcus,  may  travel  to  the  uterus,  notwithstanding 
the  bacillus  of  Doderlein. 

J.  Whitridge  Williams  made  a  study  of  the  bacteria  in  the  vagina 
of  ninety-two  pregnant  women  and  came  to  the  following  conclusions: 

"1.  We  agree  with  Kronig  that  the  vaginal  secretion  of  pregnant 
women  does  not  contain  the  usual  pyogenic  cocci,  having  found  the 
staphylococcus  epidermidis  albus  only  twice  in  ninety-two  cases,  but 
never  the  streptococcus  pyogenes  or  the  streptococcus  aureus  or  albus. 

"2.  The  discrepancy  in  the  results  of  the  various  investigators  is 
due  to  the  technique  by  which  the  secretion  is  obtained. 

"3.  As  the  vagina  does  not  contain  pyogenic  cocci,  infection  from 
them  is  impossible,  and  when  they  are  found  in  the  puerperal  uterus, 
they  have  been  introduced  from  without. 

"  4.  The  gonococcus  is  occasionally  found  in  the  vaginal  secretion, 
and  during  the  puerperium  may  extend  from  the  cervix  into  the  uterus 
and  tubes. 


86  BACTERIOLOGICAL  EXAMINATION 

"  5.  It  is  possible,  but  not  yet  demonstrated,  that  in  very  rare 
instances  the  vagina  may  contain  bacteria,  which  may  give  rise  to 
sapremia  and  putrefactive  endometritis  l)y  auto-infection. 

"  G.  Death  from  puerperal  infection  is  probably  always  due  to 
infection  from  without,  and  is  usually  the  result  of  neglect  of  aseptic 
precautions  on  the  part  of  the  physician  and  nurse. 

"All  infections  of  the  vulva  and  vagina  are  mixed  infections.  The 
gonococcus,  tubercle  bacillus,  diphtheria  bacillus,  staphylococcus, 
and  streptococcus  never  exist  alone,  though  they  may  so  dominate 
in  numbers  and  clinical  phenomena  as  to  be  regarded  as  an  isolated 
infection." 

Gonococcus  Infection. — This  type  of  infection  is  rarely  primary  during 
the  period  of  sexual  maturity,  but  in  infancy  and  in  old  age  when  the 
epithelium  offers  less  resistance,  primary  vulvovaginitis  is  relatively 
frequent.  The  gonococcus  is  often  found  in  the  secretions  of  the 
vagina  and  vulva  and  occasionally  when  the  secretion  is  not  purulent. 
The  Bartholinean  gland,  or  rather  the  outlet  of  the  gland,  is  the  most 
frequent  point  of  attack  in  the  vulva.  It  is  said  that  the  gonococcus 
never  invades  the  deeper  ramifications  of  the  gland.  Here,  as  else- 
where, the  infection  is  mixed. 

Tubercle  Bacillus  Infection. — This  is  rarely  a  primary  infection.  As 
a  rule,  the  infection  is  secondary  to  that  of  the  uterus;  more  rarely 
to  the  vulva,  bladder,  or  rectum.  Direct  infection  is  possible,  as  is 
also  infection  through  the  blood. 

Diphtheria  Bacillus  Infection. — ^This  is  commonly  a  puerperal  infection 
conveyed  directly  to  an  injured  tissue.  The  author  has  seen  but  one 
such  case.  This  one  responded  promptly  to  the  antitoxin  of  diphtheria. 
The  nurse  in  attendance  acquired  a  diphtheritic  sore  throat  from  the 
patient. 

Aerogenous  Infection. — This  infection  is  manifested  by  the  formation 
of  small  subepithelial  cysts  containing  gas  (emphysematous  vaginitis). 
The  infection  is  usually  associated  with  pregnancy. 

Bacteriology  of  the  Uterus. — Under  normal  conditions  the  uterus  is 
at  all  times  free  from  microorganisms,  both  pathogenic  and  non-patho- 
genic. The  normal  cervical  secretion  is  said  to  possess  a  germicidal 
power.  Even  in  chronic  inflammation  of  the  uterus,  bacteria  are  rarely 
demonstrated.  Uterine  infections  are  identical  with  those  of  the  tube 
and  are  classified  either  as  mixed  or  specific.  It  is  highly  probable 
that  all  uterine  infections  are  mixed.  The  so-called  specific  infections 
are  those  in  which  a  certain  pathogenic  microorganism  (streptococcus, 
gonococcus,  tubercle  bacillus)  predominates.  According  to  Sinclair 
the  causes  of  immunity  from  infection  of  the  cervix  are: 

1.  Alkaline  reaction  of  the  cervical  secretion. 

2.  Small  caliber  of  the  cervix. 

3.  Increased  muscular  power  in  the  walls  of  the  cervix. 

4.  The  downward  stream  of  the  cervical  secretion. 

5.  Germicidal  quality  of  the  cervical  secretion. 


BACTERIOLOGY  OF   THE  FALLOPIAN   TUBES  87 

Bacteriology  of  the  Fallopian  Tubes. — Under  normal  conditions  no 
microorganisms  exist  in  the  tubes.  Few  bacteriological  examinations 
have  been  made  from  catarrhal  salpingitis,  and  the  results  are  not 
definite. 

In  the  purulent  forms  of  salpingitis  a  large  number  of  observers 
have  made  careful  observations.  Frank  T.  Andrews/  in  writing  of 
the  causes  of  salpingitis,  has  presented  a  valuable  series  of  statistics 
collected  from  28  sources.  The  following  table  was  constructed  bj^ 
Andrews : 

In  a  total  of  684  observations  the  following  percentages  were  found : 

Sterile 55.0 per  cent. 

Only  saprophytes 6.0  per  cent. 

Gonococcus 22. 5  per  cent. 

Staphylococcus  and  streptococcus 12.0  per  cent. 

Pneumococcus 2.0  per  cent. 

Bacillus  con  communis 2.5  per  cent. 

Gonococcus. — The  gonococcus  of  Xeisser  was  found  155  times  in 
308  cases  in  which  microorganisms  were  demonstrated.  Without 
doubt  a  large  proportion  of  the  sterile  tubes  was  originally  infected 
by  the  gonococcus.  The  gonococcus  frequently  escapes  detection 
because  it  disappears  early  from  the  pus  contents  of  the  tubes,  and  it 
is  extremely  difficult  to  recognize  the  gonococcus  in  the  wall  of  the  tube, 
though  they  have  been  known  to  exist  many  years.  In  36  cases  of 
gonorrheal  salpingitis,  other  bacteria  were  found  in  5. 

Streptococcus  and  Staphylococcus. — ^These  two  microorganisms  are  con- 
sidered together,  first,  because  they  so  commonly  coexist,  and,  second, 
because  their  anatomical  effects  are  much  the  same.  Their  virulence  in 
the  tube  is  variable. 

Pneumococcus  of  Frankel. — The  pneumococcus  infections  of  the  tube, 
which  have  been  reported,  bear  no  relation  to  pneumonia.  The  infec- 
tion of  the  tube  is  probably  acquired  in  these  cases  by  direct  extension 
from  the  lower  genital  tract. 

Bacillus  Coli  Communis. — This  infection  is  very  often  mixed,  the 
colon  infection  being  usually  secondary  to  other  forms.  In  the  majority 
of  cases  the  presence  of  the  colon  bacillus  implies  adhesions  binding 
the  tube  to  the  bowel,  though,  as  stated  by  Andrews^  the  infection 
may  extend  through  the  bowel  wall,  along  the  peritoneum  to  a  non- 
adherent tube,  or  may  travel  up  through  the  genital  tract. 

Typhoid  Bacillus. — Xo  direct  connection  has  been  traced  between 
typhoid  infection  of  the  tube  and  typhoid  fever,  though  it  is  possible 
that  the  typhoid  bacillus  may  exist  in  tissues  years  after  an  attack 
of  typhoid  fever. 

Saprophytic  Bacteria. — Xon-pathogenic  bacteria  of  the  saprophytic 
order  are  not  infrequently  found  in  salpingitis. 

Infectious  Granulomata.— Of  the  infectious  granulomata,  tuberculosis 
ranks  first  in  frequency  and  in  clinical  importance. 

1  American  Journal  of  Obstetrics,  February,  1904. 


88  BACTERIOLOGICAL  EXAMINATION 

Tuhercuhsis. — In  a  total  of  100  cases  of  pyosalpinx  collected  by 
Andrews,  10  per  cent,  were  tuberculous.  The  tubes  are  usually  the 
primary  seat  of  genital  tuberculosis — 57  out  of  G7  cases  (JMeyer). 
On  the  other  hand,  Orthmann  states  that  primary  tubal  tuberculosis 
occurs  in  18  per  cent,  of  genital  tuberculosis  in  women;  this  in  a  series 
of  168  cases.  Secondary  tubal  tuberculosis  is  relatively  common,  and 
is  most  often  acquired  through  the  blood. 

Syphilis. — Syphilis  is  rarely  identified  in  the  tube.  Undoubtedly 
syphilitic  lesions  of  the  tube  are  common  to  general  syphilitic  infec- 
tion, but  it  is  difficult  to  identify  them  as  such.  But  three  cases  are 
recorded. 

Adinomiicosis. — Actinomycosis  of  the  tube  is  a  great  rarity. 

Bacteriology  of  the  Ovary, — Infections  of  the  ovary  are  almost  with- 
out exception  secondary  to  tubal  infection,  and  hence  the  bacteriology 
of  ovarian  abscesses  is  in  most  part  identical  with  that  of  purulent 
salpingitis.  Primary  ovarian  abscesses  are  exceedingly  rare,  though  the 
possibility  of  infection  travelling  to  the  ovary  by  way  of  the  blood- 
lymph  channels  or  directly  through  the  genital  tract  without  visible 
effects  until  the  ovary  is  reached,  cannot  be  denied.  Sutton  says  that 
primary  ovarian  abscesses  are  always  tuberculous.  This  statement  is 
not  verified  by  experience.  Martin  collected  55  cases  of  ovarian 
abscesses  from  the  literature,  and  of  this  number  35  contained  bacteria, 
the  remaining  20  were  sterile.  The  gonococcus  and  the  bacillus  coli 
communis  were  the  most  frequently  found.  Staphylococci  streptococci, 
pneumococci,  and  the  typhoid  bacillus  were  relatively  infrequent. 
The  rule  that  bilateral  infection  of  the  appendages  speaks  for  gonorrhea 
and  unilateral  involvement  for  puerperal  infection  has  many  exceptions. 
Suppurating  ovarian  cysts  have  been  discussed  by  Cumston.  Dermoid 
cysts  are  particularly  susceptible  to  infection  and  the  development  of 
abscesses.  The  organisms  which  have  been  mentioned  have  been 
found  in  these  cysts.  Inasmuch  as  suppurating  cysts  are  almost  invari- 
ably adherent  to  the  bowel,  the  colon  bacillus  is  of  common  occurrence, 
but  more  often  as  a  secondary  infection.  The  size  of  the  abscess  is  no 
criterion  of  the  virulence  of  the  pus.  Fraisse  removed  a  cj'st  containing 
fifteen  liters  of  sterile  pus.  Such  abscesses  at  one  time  undoubtedly 
contained  either  pathogenic  or  saprophytic  organisms.  The  periodic 
congestion  of  the  ovary  and  rupture  of  the  Graafian  follicles,  together 
with  the  tendency  of  the  ovary  to  the  formation  of  new^growths  and 
to  torsion  of  the  pedicle,  render  the  ovary  peculiarly  susceptible  to 
infection. 

Streptococcus  and  Staphylococcus. — These  infections  are  common;  they 
frequently  follow  upon  labor  and  abortion.  The  virulence  of  the  infec- 
tion and  the  resistance  of  the  individual  determine  the  clinical  picture. 
The  lesion  in  the  ovary  is  but  a  part  of  the  more  general  infection 
of  the  lower  genital  tract  and  occurs  at  intervals  of  days  weeks,  and 
months  subsequent  to  the  initial  infection. 

Gonococcus. — This  infection  doubtless  ranks  first  in  point  of  frequency. 
Reymond  affirms  that  the  gonococcus  always  attacks  the  surface  of 


BACTERIOLOGY  OF  THE  PERITONEUM  89 

the  ovary,  and  is  never  found  in  the  pus  of  an  ovarian  abscess.  The 
gonococcus  can  enter  the  substance  of  the  ovary  through  the  blood 
and  lymph  channels  and  through  the  follicles  and  corpora  lutea. 

Bacillus  Coli  Communis. — This  is  said  to  never  occur  in  the  absence 
of  adhesions  binding  the  ovary  to  the  bowel.  The  infection  is  conse- 
quently mixed  in  the  majority  of  cases.  It  is  probable  that  the  infection 
travels  also  through  the  genital  tract  to  the  ovary. 

Pneumococcus. — This  form  of  infection  has  been  recorded  by  several 
observers.  A  pure  culture  of  the  pneumococcus  has  been  obtained 
from  the  pus  in  the  abscess.  In  none  of  the  cases  was  there  a  recent 
history  of  pneumonia. 

Tubercle  Bacillus. — This  infection  is  by  no  means  so  infrequent  as 
the  early  writers  would  have  us  believe.  Miliary  tubercles  are  observed 
by  the  microscope  in  ovaries  that  appeared  perfectly  normal.  Primary 
infection  of  the  ovary  is  most  unusual.  The  infection  is  almost  invariably 
secondary,  but  it  is  not  always  possible  to  determine  the  initial  point  of 
infection.  It  is  generally  believed  that  the  tubes  are  the  primary  seat 
in  the  majority  of  cases.  Schottlander  believes  the  peritoneum  to  be  the 
primary  source  of  the  infection,  but  does  not  exclude  the  tubes  as  a 
possible  source.  It  is,  of  course,  possible  for  the  tubercle  bacillus  to  pass 
from  the  vagina  by  way  of  the  uterus  and  tubes  to  the  ovary,  or  from 
the  vagina  through  the  broad  ligaments  to  the  hilum  of  the  ovary.  In 
general  miliary  tuberculosis  the  ovary  is  especially  liable  to  be  attacked 
by  way  of  the  blood.  In  48  cases  of  ovarian  tuberculosis  Orthmann 
traced  the  infection  to  the  tubes  in  26  and  to  the  peritoneum  in  22. 

Bacteriology  of  the  Peritoneum  and  Pelvic  Cellular  Tissue. — The 
involvement  of  the  peritoneal  and  cellular  tissues  of  the  pelvis  is 
almost  invariably  secondary  to  infections  of  the  uterus,  tubes,  ovaries, 
cervix,  vagina,  bladder,  or  rectum.  The  bacteriology  of  pelvic  cellulitis 
and  peritonitis  is  therefore  that  of  vaginitis,  metritis,  salpingoovaritis, 
cystitis,  and  proctitis.  In  puerperal  infection  the  streptococcus  and 
staphylococcus  are  about  equally  liable  to  infect  the  pelvic  cellular 
tissue  and  peritoneum.  Not  so  with  the  gonococcus  and  tubercle 
bacillus,  which  attack  by  preference  the  peritoneum.  The  colon 
bacillus  and  tubercle  bacillus  doubtless  very  frequently  pass  througli 
the  bowel  to  the  peritoneum  and  cellular  tissue,  though  with  these 
organisms,  as  with  all  others,  the  usual  avenue  of  infection  is  the 
genital  tract. 


CHAPTER   V 

GENERAL  PHYSICAL  EXAMLXATIOX— EXA:\nXATIOX 
OF  EXTERXAL  AXD   IXTERNAL  GEXITALS 

GENERAL  PHYSICAL  EXAMINATION 

Preliminary  ^Measures  :         Percussion 

External  Abdominal  Ex.\mination  i         Auscultation 

Inspection  I  '   Mensuration 

Palpation  I 

Preliminary  Measures. — After  the  history  has  been  taken,  the  next 
st^p  is  to  determine  by  a  general  physical  examination  the  possible 
bearing  which  some  remote  affection  may  have  upon  the  pelvic 
organs. 

Giving  attention  more  particularly  to  the  abdomen  and  pelvis,  the 
following  outline  will  serve  to  indicate  the  methods  to  be  employed 
in  a  systematic  and  thorough  physical  examination,  as  well  as  the 
order  in  which  practical  experience  has  sanctioned  their  usage. 

N^o  invariable  order  can  be  adopted;  circumstances  will  alter  the 
general  routine;  but  it  is  well  to  follow  a  definite  method  of  pro- 
cedure as  closely  as  possible.  The  habit  of  making  a  systematic 
routine  examination  will  not  infrequently  eliminate  many  errors  in 
diagnosis.  The  examiner  will  not  likely  be  content  with  any  single, 
explanation  for  the  patient's  complaint,  but  will  seek  farther  for  other 
possible  lesions.  The  writer  recalls  a  case  in  which  hemorrhage  was 
the  symptom  complained  of.  On  physical  examination  an  interstitial 
fibroid  was  discovered.  This  was  believed  to  explain  the  hemorrhage, 
and  a  hysterectomy  was  performed.  Li  the  cavity  of  the  uterus  was  a 
cauliflower  carcinoma,  which  had  not  been  suspected.  The  examina- 
tion had  not  been  complete;  when  a  single  cause  for  the  hemorrhage 
was  discovered  no  further  search  was  made.  Had  a  more  conservative 
operation  been  performed  and  the  uterus  not  removed,  the  more  serious 
of  the  lesions  would  have  been  overlooked.  !!>  learn  from  such  experi- 
ences that  ice  should  not  be  content  with  the  finding  of  a  single  cause  for  a 
given  ymptom,  but  shoidd  search  for  cdl  possible  cavses,  inasjuvch  as  two 
or  more  morbid  conditions  may  contribute  to  the  symptom. 

In  making  a  physical  examination  care  should  be  taken  not  to  injure 
the  structure  examined;  and  the  examiner  should  always  endeavor  to 
avoid  inflicting  pain.  The  more  skilled  the  examiner  the  more  careful 
and  gentle  he  is.  A  vaginal  examination  may  cause  great  discomfort, 
and  serious  damage  may  be  done  to  an  inflamed  mucous  membrane 


EXTERNAL  ABDOMINAL  EXAMINATION  91 

or  malignant  growth.  As  the  result  of  a  bimanual  examination 
roughly  made,  not  only  much  suffering  may  be  caused,  but  cysts  may 
be  ruptured,  abscesses  may  break  into  the  peritoneal  cavity,  the 
gestation  sac  of  an  ectopic  pregnancy  may  be  ruptured,  adhesions  may 
be  torn,  and  in  the  use  of  the  sound,  curet,  and  speculum,  serious  and 
even  fatal  injuries  may  be  sustained.  While  an  exact  diagnosis  is 
desired  in  the  first  examination,  it  is  seldom  absolutely  necessary  and 
is  frequently  impossible.  Certain  procedures,  such  as  catheterizing  the 
ureters,  must  often  be  postponed  for  a  subsequent  examination. 

It  is  seldom  necessary  to  make  an  examination  during  the  menstrual 
period.  It  is  not  only  objectionable  to  the  patient,  but  at  this  time 
the  pelvic  viscera  are  congested,  and  there  is  an  added  risk  of  injury. 
During  the  menstrual  period  the  cervix  is  softened  and  somewhat 
patulous,  and  for  this  reason  Simpson  has  advised  the  exploration  of 
the  uterine  cavity  during  menstruation  for  the  detection  of  foreign 
growths.  The  added  risk  of  infection  and  injury  would  seem  to  con- 
tra-indicate  such  a  practice. 

The  intermenstrual  period  is  therefore  chosen  for  local  examinations 
and  treatments,  for  the  reasons  that  the  conditions  then  found  are 
more  nearly  normal  and  there  is  less  risk  of  injury.  Furthermore,  it 
is  best  to  make  the  examination  at  a  time  when  the  patient  is  in  a 
condition  the  nearest  possible  to  the  normal.  To  this  end  the  exami- 
nation should  not  be  made  immediately  after  a  full  meal,  or  when  for 
any  reason  the  patient  is  exhausted  and  nervou'. 

Whenever  possible  the  patient  should  be  examined  on  a  table  in  a 
good  light.  Whatever  the  table  used  it  should  be  of  convenient  width 
and  length  to  permit  the  patient  to  assume  any  desired  position.  It 
should  be  so  placed  as  to  be  approached  by  the  examiner  from  all  sides, 
and  should  be  of  convenient  height  to  allow  him  to  proceed  without 
assuming  an  unnatural  and  strained  attitude. 

Fig.  14  shows  a  correct  table  for  the  making  of  examinations  and 
operations.  This  table  was  designed  by  Dr.  L.  E.  Schmidt,  of  Chicago, 
and  has  the  special  advantage  of  directing  the  buttocks  well  over  the 
edge  of  the  table,  thereby  favoring  instrumental  examinations  of  the 
bladder,  vagina,  and  rectum. 

Frequently  a  patient  must  be  examined  on  a  bed  or  couch.  The 
author  does  not  favor  the  examining  chair  because  of  its  formidable 
appearance,  its  cumbersome  weight,  and  the  inconvenience  with  which 
the  position  of  the  patient  is  changed. 

External  Abdominal  Examination. — Inspection. — It  is  well  to  expose 
the  abdomen  by  removing  the  corset  and  all  constriction  about  the 
waist.  A  sheet  should  cover  the  upper  portion  of  the  trunk  to  the 
waist  line;  another  sheet  should  cover  the  lower  extremities  and  hips, 
as  seen  in  Fig.  15. 

The  chief  value  of  inspection  is  to  determine  abnormalities  in  the 
contour  of  the  abdomen.  Among  the  points  to  be  observed  are  the 
size  of  the  abdomen,  its  form,  the  site  of  a  convexity  or  depression,  the 
laxity  or  tension  of  the  abdominal  wall,  the  retraction  or  protrusion 


92 


Q  EN  ERA  L  PH  YSICA  L  EX  A  MIX  A  TIOX 


of  the  umbilicus,  the  presence  of  Hnea  albicantes,  pigmentations, 
(hstended  veins,  hernia,  skin  diseases,  peristaltic  movements  of  the 
intestine,  pulsations  of  the  aorta  as  seen  through  the  thin  abdominal 


Examiaiag  table.     (Schmidt.) 
Fig.  15 


Position  for  abdominal  examination. 


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PA  LP  ATI  ox  93 

wall,  and  fetal  or  respiratory  movement.-.  \'ariation.->  in  the  eontour 
of  the  abdomen  produced  by  t\Tapany,  ascitic  fluid,  tumors,  and  thick 
parietes  are  readily  recognized  by  a  competent  observer. 

In  a  thick,  fatty  abdominal  wall  the  abdomen  is  flattened  and  the 
flanks  protrude  and  sag  downward  when  the  patient  lies  on  her  back. 
Great  transverse  folds  are  formed.     (See  Plate  I.j 

Free  ascites,  with  the  patient  in  the  dorsal  position,  causes  a  bulging 
in  the  flanks  and  a  flattening  of  the  anterior  abdominal  wall.  With 
change  in  position  of  the  patient  the  contour  of  the  abdomen  is  altered. 
(See  Plate  II.j 

In  ovarian  cysts  the  abdomen  is  irregularly  ovoid.  In  the  A'ery 
large  cysts,  or  where  the  pedicle  is  long  and  the  cyst  is  freely  movable, 
the  abdomen  may  be  evenly  distended.  When  tKe  abdominal  wall 
is  thin  and  the  cyst  large  and  multilocular,  it  is  sometimes  possible 
to  see  the  irregular  elevations  through  the  abdominal  wall.  (See 
Plate  III ) 

Large  uterine  fibroids  may  e\enly  distend  the  abdomen,  but  more 
frequently  cause  an  irregtilar  protuberance.  fSee  Plates  IV  and  V.j 
In  interstitial  fibroids  the  abdominal  enlargement  is  inclined  to  be 
more  median  than  in  ovarian  cysts.     (See  Plate  IV.j 

In  excessive  distention  of  the  abdomen  the  skin  is  white  and  shiny, 
and  often  streaked  with  irregular  red  lines. 

Additional  information  may  be  gained  by  watching  the  movements 
of  the  abdominal  wall.  The  excursions  of  the  abdominal  wall  are 
restricted  during  respiration  by  the  presence  of  painful  lesions  within 
the  abdomen,  such  as  peritonitis,  circumscribed  abscesses  of  the  abdomi- 
nal viscera,  intestinal  obstruction,  and  intraperitoneal  hemorrhages. 
Large  abdominal  tumors  also  inhibit  the  excursions  of  the  abdominal 
wall  over  the  region  occupied  by  the  tumor.  Tumors  of  the  upper 
abdomen,  if  not  firmly  adherent,  will  usually  move  with  the  respirations, 
while  pelvic  tumors  are  not  affected  by  the  respiratory  movements. 

Inspection  is  of  assistance  in  recognizing  the  presence  of  a  living 
fetus  in  utero.  The  active  fetal  moA'ements  may  be  seen  and  the 
intermittent  contractions  of  the  pregnant  uterus  are  discernible.  In 
intestinal  obstruction  the  peristaltic  wave  may  be  seen  to  pass  in  the 
direction  of  the  distended  gut. 

Pigmentation  of  the  skin  in  the  median  line  of  the  abdomen  suggests 
a  previous  pregnancy,  as  do  also  strise. 

Palpation. — The  abdomen  is  best  palpated  with  the  patient  in  the 
dorsal  position.  The  head  and  chest,  if  elevated,  will  diminish  the  field 
of  exploration.  When  it  is  desired  to  note  the  effect  of  change  in 
position  upon  the  abdominal  contents,  the  erect,  the  knee-elbow,  or  the 
lateral  position  may  be  assumed. 

Preliminary  to  all  abdominal  and  pelvic  examinations,  the  bladder 
and  rectum  must  be  empty  and  all  constricting  bands  of  clothing 
removed.  The  examiner's  hands  should  be  warm  and  the  finger  nails 
cut  short.  Both  hands  should  be  used.  They  should  be  laid  gently 
upon  the  abdomen,  with  steady  and  firm  pressure,  avoiding  all  sudden 


94 


GENERAL  PHYSICAL  EXAMINATION 


and  unexpected  movements.  The  patient  should  be  instructed  to 
breathe  cinietly,  with  the  mouth  open.  Her  attention  may  be  drawn 
froni  the  examination  by  asking  questions  concerning  some  other 
portion  of  her  body.  In  this  manner,  with  the  abdominal  walls  thin 
and  relaxed,  it  may  be  possible  to  palpate  the  projecting  vertebrae, 
the  posterior  wall  of  the  pelvis,  the  promontory  of  the  sacrum,  and 
the  pulsating  aorta. 

Thick  and  tense  abdominal  walls  may  prevent  satisfactory  palpation 
of  the  abdomen,  thereby  necessitating  an  anesthetic.  Very  often,  by 
care  and  patience,  the  tendency  to  contract  the  abdominal  walls  may 
be  overcome  Avithout  resorting  to  anesthesia.  Remember  that  it  is 
possible  to  do  harm  by  rupturing  collections  of  blood,  cysts,  and 
abscesses,  and  by  exciting  a  limited  or  latent  inflammation  to  extend 
to  surrounding  structures. 


Fig.  16 


Palpation  of  the  colon. 


For  couA-enience  of  description  the  abdomen  may  be  divided  into 
quadrants  (Fig.  17).  These  are  named  respectively  the  right  upper, 
the  left  upper,  the  right  lower,  and  the  left  lower' quadrants. 

Before  determining  the  nature  of  a  swelling,  it  is  necessary  to  identify 
it  either  as  growing  from  the  pelvis  or  from  the  abdomen,  and  to 
demonstrate  its  relation  to  the  viscera  and  to  the  abdomin'al  wall. 

It  is  well  to  follow  a  routine  system,  beginning  below  and  proceeding 
upward.  If  the  preliminary  step  of  emptying  the  bladder  and  bowels 
is  taken  there  should  be  no  confusion  with  a  fecal  tumor  and  distended 
bladder.  Sensitiveness,  tension,  thickness,  and  consistency  of  the 
abdominal  wall  are  noted  by  systematically  palpating  symmetrical 


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PALPATION 


95 


parts  and  comparing  them.  Xo  considerable  pressure  need  be  exerted 
in  determining  these  facts.  "When  sensitiveness  is  found  nervous  irri- 
tabiHty  and  inflammation  should  be  carefully  distinguished.  When 
deep  pressure  is  tolerated  in  the  presence  of  superficial  tenderness, 
inflammation  can  be  almost  surely  excluded.  All  tumors  of  the 
abdominal  wall  move  with  the  wall,  and  may  be  lifted  up  with  it. 
The  connection  of  a  tumor  wdth  the  skin  is  recognized  by  inability 
to  lift  the  skin  apart  from  the  tumor. 


Fig.   17 


pper  Right 
Quadrant 


Lower  Right 
Quadrant 


Upper  Left^; 
Quadrant 


Lower  Left 
Quadrant 


Diagram  of  the  areas  into  -which  the  abdomen  mav  be  divided. 


All  intraperitoneal  tumors  and  viscera  move  with  respiration;  the 
nearer  the  diaphragm  the  greater  the  excursions.  If  the  organ  or  tumor 
is  adherent  or  is  incarcerated  the  excursions  will  be  limited.  These 
isochronous,  respiratory  movements  are  readily  recognized  by  the  hand, 
and  under  favorable  conditions  may  be  recognized  by  inspection.  An 
organ  or  tumor  lying  underneath  the  peritoneum,  if  protruding  into 
the  peritoneal  cavity,  may  be  affected  by  respiratory  movements.  Such, 
for  example,  may  be  the  case  with  a  movable  kidney  or  a  pedunculated 


96 


GENERAL  PHYSICAL  EXAMINATION 

Fia.  IS 


Demonstrating  the  thickness  of  the  abdomen. 
Fig.  19 


Showing  position  of  various  organs.     G.BL,  gall-bladder;  Spl.,  spleen;  K,  kidney;   Vr.,  ureter; 
T-0,  tube  and  ovary;  Ut.,  uterus;  BL,  bladder. 


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PERCUSSION  97 

subserous  fibroid.  All  tumors  arising  in  the  pelvis  tend  to  grow 
upward. 

The  contour  of  the  swelling  and  its  consistency  are  determined  by 
palpation.  It  is  important  to  recognize  periodical  alterations  in 
consistency  in  connection  with  the  differential  diagnosis  between 
pelvic  or  abdominal  swellings  and  a  pregnant  uterus.  No  swelling 
other  than  a  pregnant  uterus  contracts  intermittently.  The  softening 
of  a  tumor  speaks  for  a  degenerative  process.  When  the  swelling  is 
deep-seated  or  the  abdominal  wall  thick  and  tense,  it  may  be  impossible 
to  determine  the  consistency  and  contour  of  the  swelling.  Fluctuation 
is  best  detected  by  percussion  associated  with  palpation,  and  when 
elicited  speaks  for  the  presence  of  fluid.  The  readiness  of  response 
to  impulse,  indicates  to  some  extent  the  consistency  of  the  fluid.  The 
examiner  is  often  at  a  loss  to  decide  whether  or  not  fluid  is  present. 
Tense  cysts  may  not  fluctuate,  and,  on  the  other  hand,  soft  tumors 
may  appear  to  fluctuate. 

The  connection  of  the  swelling  with  other  tumors  and  viscera  may 
be  determined  by  palpation.  The  exact  location  of  the  tumor  is  noted, 
and  by  palpation  is  often  traced  to  a  particular  organ.  By  changing 
the  position  of  the  patient,  additional  information  may  be  obtained 
regarding  the  attachment  of  the  swelling.  Spencer  Wells  has  pointed 
out  that  non-adherent-,  pedunculated  tumors  of  the  pelvis  gravitate  into 
the  abdominal  cavity  when  the  knee-chest  position  is  assumed. 

Percussion. — The  abdomen  is  best  percussed  with  the  patient  in  the 
dorsal  position.  When  it  is  desired  to  demonstrate  by  percussion  the 
change  in  position  of  a  tumor  or  fluid,  the  patient  may  assume  any 
required  position. 

Since  the  normal  percussion  tone  of  the  abdomen  differs  according 
to  the  contents  of  the  stomach  and  bowels,  the  results  obtained  by 
percussion  are  not  altogether  reliable.  The  normal  range  of  motion 
in  the  abdominal  and  pelvic  viscera  also  adds  to  the  uncertainty  of 
the  conclusions  arrived  at  by  percussion.  Furthermore,  it  is  impossible 
to  compare  the  percussion  note  on  corresponding  sides  as  is  done  in 
percussing  the  chest.  Percussion  is  to  be  regarded  as  an  auxiliary 
to  palpation. 

In  proceeding  it  is  well  to  go  over  the  entire  abdomen  in  a  systematic 
manner.  If  firm  pressure  is  made  by  the  fingers  the  intestines,  unless 
adherent,  will  be  pushed  aside,  and  the  underlying  organ  or  tumor 
can  be  directly  percussed.  Percussion  is  of  the  greatest  value  in  demon- 
strating the  presence  or  absence  of  intestine  lying  in  front  of  the  organ 
or  tumor.    All  other  conditions  are  better  elicited  by  palpation. 

In  ascites  the  dull  percussion  note  of  the  fluid  is  found  in  the  most 
dependent  portion  of  the  abdomen,  and  the  tympanitic  note  of  the  intes- 
tine is  found  above  the  fluid.  When  the  mesentery  is  short  or  the  bowel 
fixed  by  adhesions,  the  above  findings  are  not  elicited.  If  gas  does  not 
distend  the  intestine,  or  if  fecal  matter  fills  the  intestine,  the  tympanitic 
note  is  not  elicited  in  contrast  to  the  dull  note  of  the  fluid.  When  the 
ascitic  fluid  greatly  distends  the  abdomen  there  may  be  no  change  in 


98 


GEXERAL   PHYSICAL   EXAMIXATION 
Fig.  20 


Breaking  the  fat  wave  in  percussing  for  fluid  in  the  atdomen. 
Fig.  21 


Demonstrating  the  percussion  wave  in  abdominal  ascites 


MENSURATION  99 

the  area  of  dulness.  When  there  is  a  small  amount  of  ascitic  fluid 
the  intestine  may  float  to  the  side  of  the  abdomen  and  give  a  tympanitic 
note  together  with  fluctuation. 

When  an  ovarian  cyst  distends  the  abdomen  the  percussion  note  is 
dull  in  front  and  the  tympanitic  note  of  the  intestine  is  found  low  in 
the  flanks. 

Auscultation.  —  This  is  of  little  value  except  in  the  diagnosis  of 
pregnancy,  but  should  be  a  part  of  the  routine  examination  in  all 
abdominal  swellings  which  resemble  pregnancy.  Other  than  the  sounds 
referable  to  the  fetus,  the  placenta,  and  the  pregnant  uterus,  there  may 
be  heard  over  the  abdomen  the  maternal  heart  tones,  pulsations  of  the 
aorta,  murmurs  of  abdominal  aneurysms,  gurgling  of  gas  in  the  bowel 
and  stomach,  and  the  friction  sounds  caused  by  the  rubbing  together 
of  rough  surfaces. 

The  patient  should  be  in  the  dorsal  position,  with  the  legs  sufficiently 
flexed  to  relax  the  abdominal  walls,  yet  not  to  the  extent  of  interfering 
with  the  examination.  The  ear  or  stethoscope  may  be  employed, 
preferably  the  latter. 

The  uterine  bruit  is  not  to  be  mistaken  for  the  bruit  that  is  heard 
in  about  50  per  cent,  of  uterine  tumors  and  occasionally  in  ovarian 
cysts.  A  similar  bruit  has  been  heard  over  the  tumors  of  the  liver, 
spleen,  and  the  retroperitoneal  spaces.  No  such  sound  has  been  heard 
over  tumors  of  the  kidney. 

Mensuration.  —  This  is  of  some  importance  in  the  diagnosis  of  ab- 
dominal swellings.  It  finds  its  greatest  service  in  obstetric  practice. 
It  is  a  fairly  precise  means  of  determining  the  rate  of  growth  of  an 
abdominal  swelling. 

Exact  measurements  are  difficult,  because  of  the  variable  degree 
of  distention  of  the  intestine  and  the  shifting  of  the  abdominal  tumor. 
There  must  be  a  convexity  of  the  abdomen;  otherwise,  comparative 
measurements  would  be  of  no  value. 

An  ordinary  tape-measure  will  answer  the  purpose.  The  measure- 
ments to  be  taken  are:  the  greatest  circumference,  the  circumference 
at  the  level  of  the  umbilicus,  the  distance  from  the  ensiform  cartilage 
to  the  pubis,  from  the  umbilicus  to  the  anterior  superior  spine  of  the 
ilium  on  either  side,  and  the  distance  from  the  linea  alba  to  the  spine 
of  the  vertebrae.  It  is  important  for  the  purpose  of  comparison  that 
the  same  position  be  assumed  in  making  subsequent  measurements. 


CHAPTER    VI 

EXAISIIXATIOX  OF  EXTERNAL  AND  INTERNAL 
GENITALIA 


Inspection  of  External  Genitals 
Digital  Examination  of  Internal 
Genitals 
Digital  Examination  of  Vagina 


Abdominovaginal  Examination 
Palpation    of     Ureters      through 

Vagina 
Digital  Examination  of  Rectum 


Combined  ^^aginal  Examination     ;  Pelvimetry 

Inspection  of  the  External  Genitals. — The  routine  practice  of  inspect- 
ing the  external  genitals  is  unnecessary,  and  should  be  discountenanced. 
AVhen  required  the  Sims  position  or  the  ordinary  lithotomy  position  is 
assumed.  The  sheet  is  drawn  about  the  lower  extremities  and  tucked 
about  the  vulva  in  such  a  manner  as  to  make  the  least  possible 
exposure.  The  labia  are  held  apart  by  the  thumb  and  index  finger 
for  the  inspection  of  the  vestibule,  urethral  opening,  hymen,  and  the 
perineum. 

When  gonorrhea  is  suspected  the  urethra  and  Bartholinean  glands 
should  be  inspected.  When  these  structures  are  infected,  and  par- 
ticularly if  pus  can  be  expressed  from  the  urethra,  the  diagnosis  of 
gonorrheal  infection  amounts  to  a  moral  certainty. 

Recent  injuries  should  be  inspected,  but  long-standing  injuries  to 
the  pelvic  floor  can  be  detected  and  a  fair  estimate  of  their  extent 
gained  from  the  sense  of  touch  alone. 

]Malformations,  pigmentations,  varices,  edema,  and  all  the  new- 
formations  should  be  examined  by  direct  inspection. 

Digital  Examination  of  the  Internal  Genitals. — The  hidden  position 
of  the  internal  genitals  makes  it  necessary  to  examine  them  through 
one  or  more  of  the  natural  openings — i.  e.,  rectum,  bladder,  and  vagina. 
Lentil  the  end  of  the  eighteenth  century  the  vaginal  route  was  the 
only  one  used  for  such  examinations.  Little  progress  was  made  in  the 
diagnosis  of  diseases  of  the  internal  genital  organs  untU  combined 
methods  of  examination  were  introduced  by  M.' Puzos,  in  the  eighteenth 
century,  and  revived  and  elaborated  by  Sir  James  Y.  Simpson. 

The  combined  examination  is  the  only  means  of  determining  the 
size,  position,  consistency,  mobility,  sensitiveness,  and  relative  positions 
of  the  pelvic  organs. 

Digital  Examination  of  the  Vagina. — This  is  made  with  the  patient 
in  the  Sims  or  lithotomy  position,  and  rarely  in  the  erect  or  knee-chest 
position.  When  the  bare  hand  is  used  it  should  be  scrubbed  with  soap 
and  water  and  disinfected  with  lysol.  The  best  lubricant  for  the  ex- 
amining finger  is  scented  green  soap.    Vaseline  is  not  desirable,  because 


DIGITAL  EXAMIXATIOX  OF  THE  VAGIXA  101 

Fig.  22 


Patient  prepared  for  inspection  and  vaginal  examination  in  the  office. 


Fig.  23 


Patient  prepart-d  lur  inspection  and  vaginal  examination.     Hips  drawn  to  the  end  of  the  couch 

and  feet  resting  on  stools. 


102     EXAMINATION  OF  EXTERNAL  AND    INTERNAL  GENITALIA 

of  the  odor  from  the  secretions,  which  cHngs  to  the  fingers  in  spite^  of 
vigorous  scrubbing.  In  an  ordinary  digital  examination  of  the  vagina 
it  is  unnecessary  to  expose  the  vulva;  the  examination  may  be  made 
in  a  perfectly  satisfactory  manner  under  cover  of  a  sheet. 

It  should  be  the  invariable  practice  of  physicians  to  wear  a  thin 
rubber  glove  or  finger-cot  (Fig.  26)  in  making  vaginal  and  rectal  exami- 
nations. This  is  done  not  only  as  a  matter  of  cleanliness  in  preventing 
septic  infection  of  the  genital  organs,  but  as  well  to  prevent  infection 
of  the  examining  finger.    A  well-known  authority  on  skin  and  venereal 


Fig.  24 


Vaginal  cxaminutiou  with  two  fingers.     iStep  1.   The  perineum  i.s  forrilily  depressed  by  the  palmar 
surface  of  the  middle  finger,  thereby  increasing  the  vaginal  outlet. 


diseases  has  informed  the  author  that  an  average  of  one  physician  a 
week  came  to  his  office  with  a  syphilitic  infection  acquired  in  making 
examinations.  This  appalling  statement  should  make  the  examiner 
very  cautious. 

The  attitude  of  the  examiner  should  be  carefully  considered.  Fig. 
27  shows  the  correct  position,  though  the  table  is  somewhat  high  for 
convenience  and  efficiency.  The  examiner  stands  at  the  end  of  the 
table;  one  foot  rests  upon  a  low  stool;  the  elbow  of  the  examining  arm 
rests  upon  the  knee,  thereby  permitting  free  motion  in  the  forearm 
and  hand. 


DIGITAL  EXAMINATION  OF  THE  VAGINA 


103 


Choice  of  Hand. — The  choice  of  hand  will  depend  in  part  upon  the 
comparative  utility  of  the  two  hands,  but  more  upon  the  habit  acquired. 


Fig.  25 


Vaginal  examination  with  two  fingers.     Step  2.  Index  finger  is  inserted  above  the  middle  finger 
and  into  the  vaginal  outlet. 


FULL  SIZE 


Finger-cot  worn  on  the  index  finger. 


104     EXAMINATION  OF  EXTERNAL  AND    INTERNAL  GENITALIA 

As  a  general  thino;,  the  right  side  of  the  pelvis  is  best  palpated  with  the 
right  hand,  and  the  left  side  with  the  left  hand.  In  the  early  experience 
of  the  examiner  it  is  best  to  cultivate  the  sense  of  touch  in  a  single  hand, 
and  in  later  years,  as  there  are  opportunities  for  more  experience,  either 
hand  may  be  used,  with  equal  expertness. 

Fig.  27 


Combined  vaginal  examination. 


_  Number  of  Fi7igers. —When  two  fingers  can  be  introduced  without 
discomfort  to  the  patient,  the  two  will  be  found  more  effective  than 
one.  In  order  that  the  fingers  may  be  introduced  with  the  least  possible 
annoyance  to  the  patient,  the  labia  are  separated  by  the  thumb  and 
index  finger.    The  middle  finger  of  the  opposite  hand  is  inserted  into 


DIGITAL  EXAMINATION  OF  THE  VAGINA 


105 


the  vulvar  opening,  with  the  palmar  surface  restmg  upon  the  Pjmeum 
Firm  pressure  is  made  by  the  finger  upon  the  permeum.    The  vulvar 
Xt^ftherebv  deepened,  and  into  it  the  index  finger  can  be  readily 
ll^^rted  (F^^^  t;o  fingers  are  now  passed  into  the  vagma, 


Fig.  28 


Lithotomy  position. 
Fig.  29 


Knee-chest  position. 


^.aking    firm   pressure    upon    the    V^^^f^^   P^^^ 
upon  the  clitoris  and  urethra  (I'lg.  2o).     When  tne  n  „ 
inserted  the  palm  of  the  hand  is  turned  "PJ^ten         et    al'^le 
outlet  is  small,  the  mucosa  sensitive,  or  the  hjmen 


106     EXAMINATION  OF  EXTERNAL  AND  INTERNAL    GENITALIA 

fins^er  should  be  employed.  When  pain  is  caused  by  inserting  the 
finger  it  is  well  to  ask  the  patient  to  bear  down  while  the  finger  is 
being  introduced. 

Fig.  30 


Inspection  of  the  vagina  and  cervix  -with  patient  in  the  knee-chest  position. 

The  following  conditions  are  determined  by  a  simple  vaginal  exami- 
nation: the  size,  form,  and  position  of  the  vulva,  vagina,  and  vaginal 
portion  of  the  cervix;  the  condition  of  the  hymen,  whether  present 
or  absent,  perforate  or  imperforate;  the  integrity  of  the  pelvic  floor; 
the  presence  of  newgrowths  in  the  vulva,  vagina,  and  vaginal  portion 
of  the  cervix;  sensitiveness  and  fulness  in  the  vault  of  the  vagina  and 
the  capacity  of  the  pelvic  outlet. 

The  knee-chest  position  is  especially  advantageous  when  it  is  desired 
to  do  away  with  intra-abdominal  pressure  for  the  purpose  of  permitting 
the  uterus  and  freely  movable  pelvic  tumors  to  rise  out  of  tjie  small 
pelvis. 

The  erect  position  is  practised  chiefly  in  determining  the  degree  of 
prolapsus  of  the  uterus. 

After  concluding  the  examination  the  finger  is  withdrawn  and  the 
secretion  on  the  finger  inspected. 

The  Combined  Vaginal  Examination  (Bimanual). — Bishop  says:  "The 
secrets  of  success  in  bimanuel  examinations  are:  a  warm  hand,  a  gentle 


ABDOMINOVAGINAL  EXAMINATION 


107 


Fig.  31 


touch,  and  patience.  Any  hurry  is  fatal."  The  advantages  of  a  com- 
bined examination  over  a  simple  vaginal  or  rectal  examination  are 
evident.  The  combined  method  may  be  regarded  as  the  most  valu- 
able of  all  physical  explorations  of  the  pelvis.  Various  combinations 
may  be  utilized,  they  being  designated  as  abdominovaginal,  abdomino- 
rectal,  abdominovesical,  abdomino- 
vesicovaginal,  abdominovesico,  and 
rectovaginal. 

As  a  preliminary  step  to  the  exami- 
nation, the  bladder  and  rectum  are 
emptied,  all  clothing  is  made  loose 
about  the  waist,  and  the  patient  placed 
in  the  lithotomy  position. 

Abdominovaginal  Examination. — In 
order  that  this  method  of  examination 
be  properly  performed,  the  vagina 
must  be  patent  and  its  walls  relaxed. 
Furthermore,  it  is  essential  that  the 
abdominal  walls  be  sufficiently  thin 
and  relaxed  to  permit  of  depression. 
When  there  is  much  fat  in  the  ab- 
dominal wall,  a  pendulous  abdomen, 
or  tenderness  and  pain  on  pressure, 
little  or  nothing  can  be  accomplished 
by  this  method  without  the  aid  of 
an  anesthetic.  In  extreme  elongation 
of  the  vagina,  and  when  there  is  an 
excessive  deposit  of  fat  in  the  external 
genitals  and  thighs,  it  may  be  impos- 
sible to  palpate  high  in  the  vault  of 
the  vagina. 

The  bimanual  examination  is  best 
performed  in  the  lithotomy  or  dorsal 
position,  with  the  thighs  slightly 
flexed.  Little  can  be  gained  from 
such  an  examination  with  the  patient 
in  the  erect  or  knee-chest  position. 
The  side  positions,  while  awkward  and 

ill-adapted  for    general   use,    are    of    special    service    in   testing   the 
mobility  of   the  pelvic  viscera  and  tumors. 

All  that  has  been  said  in  describing  the  digital  examination  of  the 
vagina  concerning  the  choice  of  hands,  the  use  of  one  or  two  fingers, 
and  the  manner  of  introduction  of  the  fingers,  will  apply  to  the  com- 
bined method  of  examination.  The  function  of  the  hand  upon  the 
abdomen  is  to  steady  the  pelvic  organs  while  being  palpated  by  the 
fingers  in  the  vagina.  A  complete  outlining  of  the  pelvic  viscera  by 
the  external  hand  is  not  possible,  consequently  light  pressure  is  all 
that  is  required,  and  has  the  advantage  of  not  exciting  the  abdominal 


Erect  position. 


108     EXAMINATION  OF  EXTERNAL  AND  INTERNAL    GENITALIA 

muscles  to  contract.  The  tips  of  the  fingers  are  directed  toward  the 
ensiform  cartiUige  and  gradually  made  to  compress  the  abdominal  wall 
at  a  variable  point  above  the  symphysis  pubis.  With  a  thin,  flaccid 
abdominal  wall,  in  the  absence  of  large  swellings,  the  external  and 
internal  fingers  may  be  approximated  in  front  of  the  uterus  with  only 
the  vaginal  wall,  the  bladder,  and  the  abdominal  wall  intervening. 
Under  most  favorable  conditions  the  fingers  may  be  similarly  approxi- 
mated behind  the  uterus.    Lifting  the  uterus  forward  and  upward  by 

Fig.  32 


Back  view  of  Sims'  position. 


Fig.  33 


V'i 


%fs'f|f| 


Front  view  of  Sims'  position. 

the  finger  in  the  vagina,  the  uterus  may  be  palpated  over  the  entire 
surface  of  its  body,  and  at  the  same  time  the  vaginal  and  supravaginal 
surface  of  the  cervix  may  be  outlined  by  the  finger  in  the  vagina.  In 
anteversion  of  the  uterus  the  anterior  surface  of  the  uterine  body  is 
best  palpated  by  the  finger  in  the  vagina,  and  the  posterior  surface  by 
the  external  fingers.  In  retroversioflexion  the  posterior  surface  of  the 
uterus  is  best  palpated  by  the  finger  in  the  vagina  and  the  anterior 
surface  by  the  external  fingers.     When  the  uterine  body  is  enlarged  it 


ABDOMINOVAGINAL  EXAMINATION 


109 


may  be  readily  outlined  in  the  combined  examination  without  elevating 
the  uterus  by  pressure  from  below. 

Under  favorable  conditions  it  is  possible  to  determine  the  position 
of  the  uterus,  its  size,  form,  sensitiveness,  consistency,  and  mobility. 
No  manipulating  should  be  done  until  the  position  of  the  uterus  is 
determined,  and  this  is  largely  accomplished  by  vaginal  touch.  Pressure 
by  the  examining  fingers  may  correct  or  exaggerate  a  malposition  of 
the  uterus.  A  preliminary  vaginal  examination  will  serve  to  eliminate 
such  errors.  For  details  of  the  method  of  examination  in  displacements 
of  the  uterus  see  Chapter  X^'I. 


Fig.  34 


Sims'  position.     Perineum  retracted  by  an  assistant. 

Only  under  unusually  favorable  conditions  can  a  normal  tube  be 
outlined  in  a  bimanual  examination.  If  the  abdominal  walls  are 
thick  and  tense  an  anesthetic  will  be  required. 

The  uterus  is  first  located  by  the  abdominovaginal  examination. 
From  the  horn  of  the  uterus  the  hand,  passing  outward  toward  the 
sides  of  the  pelvis,  should  follow  the  tube  a  variable  distance.  The 
normal  tube  is  made  to  roll  under  the  examining  finger  like  a  cord. 
It  appears  to  be  about  the  size  of  a  slate-pencil.  At  the  fimbriated 
extremity  the  wall  is  so  thin  that  it  is  impossible,  under  normal  con- 
ditions, to  palpate  it.     When  the  uterus  is  in  retroposition,  or  when 


no     EXAMINATION  OF  EXTERNAL  AND  INTERNAL    GENITALIA 


Fio.  35 


Abdominovaginal  examination 


Fig.  36 


Proper  attitude  of  the  hand  in  making  a  vaginal  examination  with  two  fingers. 


ABDOMIXOVAGIXAL   EXAMIXATION  111 

the  tubes  have  fallen  behind  the  uterus,  or  when  the  uterus  and  tubes 
are  in  their  normal  position  and  the  vagina  is  small  and  sensitive,  the 
recto-abdominal  method  of  examination  is  preferable.  In  the  unmar- 
ried, with  the  hymen  intact,  a  recto-abdominal  examination  should  be 
made. 

^Mien  the  tubes  lie  beyond  easy  reach  of  the  examining  finger, 
traction  upon  the  cervix  with  vulsella  forceps  should  be  made  by  an 
assistant,  while  the  recto-abdominal  or  vagino-abdominal  method  is 
carried  out. 

Can  a  sound  be  passed  into  the  tubes?  Undoubtedly  the  sound 
has  been  passed  into  diseased  tubes,  but  it  is  questionable  whether  the 
normal  tube  has  ever  been  sounded.  It  is  certain  that  the  procedure 
should  never  be  attempted  for  fear  of  penetrating  the  uterus 

The  normal  ovaries  are  palpated  with  difficulty,  and  are  recognized 
by  their  position,  size,  form,  and  sensitiveness.  The  ovarian  ligament 
is  seldom  felt. 

In  seeking  the  ovary,  the  bladder  and  rectum  should  be  empty,  and 
all  constricting  clothing  removed  from  the  waist.  An  anesthetic  is  not 
always  required,  but  is  helpful  in  all  eases  and  indispensable  in  many. 
The  patient  is  placed  in  the  lithotomy  position.  The  abdominovaginal 
method  is  usually  chosen.  If  the  vagina  is  short,  resisting,  or  sensitive 
to  pressure,  or  if  the  hymen  is  intact,  it  will  be  advisable  to  make  a 
recto-abdominal  examination.  AYhen  the  ovary  lies  behind  the  uterus 
it  may  be  better  palpated  through  the  rectum. 

As  a  matter  of  routine,  it  is  advisable  first  to  locate  the  uterus, 
then  to  follow  from  the  horn  of  the  uterus  along  the  course  of  the  tube 
to  the  ovary.  The  right  ovary  is  best  detected  by  the  fingers  of  the 
right  hand  and  the  left  ovary  by  the  fingers  of  the  left  hand.  It  is  not, 
as  a  rule,  necessary  to  change  hands;  either  the  right  or  the  left  hand 
will  suffice  in  most  cases  for  the  examination  of  both  ovaries. 

The  pelvic  peritoneum  and  cellular  tissue  should  be  explored  as  far 
as  possible  to  discover  undue  sensitiveness,  cicatricial  contractions, 
inflammatory  exudates,  tumor  formations,  and    collections  of   blood. 

The  rectum  on  its  anterior  wall  may  be  explored  through  the  vagina 
and  something  learned  of  its  sensitiveness,  of  inflammatory  infiltrations, 
foreign  growths,  and  fistulous  openings,  but  the  rectovaginal  method 
of  examination  is  more  satisfactory. 

The  base  of  the  bladder  and  ureters  may  be  palpated  through  the 
anterior  vaginal  wall.  Tumors,  calculi,  inflammatory  infiltrations,  new- 
growths,  and  tenderness,  from  whatever  cause,  can  be  determined  with 
some  degree  of  satisfaction. 

A  rough  estimate  of  the  capacity  and  deformity  of  the  bony  pelvis 
can  be  made  by  the  combined  method. 

The  abdominovaginal  examination  is  of  greatest  service  in  the  differ- 
ential diagnosis  of  pelvic  tumors.  By  the  combined  method  their 
size,  form,  consistency,  rate  of  growth,  mobility,  and  relation  to  other 
structures  are  determined.  AYhen  the  tumor  is  large  and  in  the 
abdominal   cavitv  the   method  of    Schultze    may   be  employed  with 


112     EXAMISATIOX  OF  EXTERNAL  AND  INTERNAL   GENITALIA 

advantao-e  In  addition  to  the  customary  bimanual  examination  an 
assistant"  draws  the  abdominal  tumor  upward  while  traction  is  made 
upon  the  cervix  with  a  vulsellum  forceps.     (See  Plate  \11.) 

The  tumor  mav  so  closely  press  upon  the  uterus  or  be  so  closely 
adherent  to  it  that  a  line  of  distinction  between  the  two  cannot  be 
recocrnized  hv  the  examining  finger.  The  variations  m  consistency  and 
forn^,  togeth'er  with  the  use  of  the  uterine  sound,  may  determine  the 
relations.  Swellings  of  the  tubes  and  ovaries  when  small  can  be  differ- 
entiated from  the  uterus;  but  later,  as  they  increase  in  size  and  become 
displaced  liehind  or  to  the  side  of  the  uterus,  they  are  recognized  with 
difficult \-.  Likewise,  pelvic  exudates  may  blend  intimately  with  the 
uterus. '  FrequentJN'  bodies  which  are  apparently  immovable  in  one 
position  may  be  movable  in  another. 

Examination  under  narcosis  has  many  ad\'antages.  Kelly  lays 
down  the  following  rules  for  the  use  of  anesthesia  in  the  diagnosis  of 
diseases  of  women: 

1.  ^Yhen  doubt  exists  after  the  ordinary  bimanual  examination. 

2.  When  a  patient  comes  to  a  specialist  after  having  had  treatment 
for  a  long  time  at  other  hands  without  improvement. 

3.  In  all  cases  of  pelvic  peritonitis  involving  one  or  both  ovaries 
or  tubes  without  producing  any  gross  tumor,  the  anesthetic  will  aid 
much  in  determining  the  extent  of  the  disease. 

4.  Always  in  unmarried  women. 

Nitrous  oxide  will  serve  admirably  in  the  majority  of- cases.  When 
the  examination  must  be  prolonged,  as  in  the  use  of  the  cystoscope 
or  curet,  either  chloroform  or  ether  is  often  necessary. 

It  should  be  a  rule,  to  which  there  are  no  exceptions,  that  after  the  paiient 
is  asleep  and  before  the  operation  is  begun  a  thorough  bimanual  examin- 
ation should  be  made. 

Under  anesthesia  a  higher  point  may  be  reached  by  inmginating  the 
pelvic  floor .  This  is  accomplished  by  making  firm  pressure  upon  the 
vulva  and  perineum  with  the  examining  hand.  In  so  doing  a  gain  of 
one  to  two  and  a  half  inches  may  be  made.  Additional  pressure  may 
be  made  by  supporting  the  elbow  of  the  examining  arm  against  the 
hip  and  throwing  the  weight  of  the  body  against  the  arm. 

Palpation  of  the  Ureters  through  the  Vagina. — When  the  abdominal 
walls  are  relaxed  and  thin  and  when  there  is  relaxation  of  the  vaginal 
walls  it  may  be  possible  to  palpate  a  thickened  ureter  for  about  two 
inches  upward  from  the  base  of  the  bladder.  The  landmark  for  the 
pelvic  portion  of  the  ureter  is  at  the  brim  of  the  pelvis,  at  a  point  just 
outside  the  sacro-iliac  joint  and  internal  iliac  artery.  When  there  is  a 
suspicion  of  tuberculosis  of  the  urogenital  tract  an  effort  should  always 
be  made  to  palpate  the  ureter. 

Digital  Examination  of  the  Rectum.  —  In  point  of  efficiency,  digital 
examination  of  the  rectum  and,  through  the  rectum,  of  the  pelvic 
structures  ranks  next  to  the  vaginal  method,  and  in  some  conditions 
is  to  be  preferred.  In  all  difficult  and  obscure  vaginal  examinations 
a  rectal  or  rectovaginal  examination  should  be  made. 


PLATE    VII 


Palpation  of  the  Pedicle  of  an  Ovarian  Cyst. 

Two  fingers  are  inserted  into  the  rectum  and  the  opposite  hand  over  the  abdomen.  An 
assistant  makes  traction  upon  the  cervix  with  a  vulsella  forceps  while  a  third  assistant 
Rrasps  the  cyst  with  both  hands  and  draws  it  upward.  In  this  manner  the  pedicle  is  put 
Spon  the  stretch  and  can  be  engaged  between  the  fingers  m  the  rectum  and  those  on  the 
abdomen. 


DIGITAL  EXAMINATION  OF  THE  RECTUM 


113 


Fig.  37 


Inspection  of  the  anus. 


Fig.  38 


X-^^A, 


Abdominoreotal  e.xamination. 


114     EXAMINATION  OF  EXTERNAL  AND  INTERNAL    GENITALIA 

The  Simple  Rectal  Touch.-^Xhen  for  any  reason  a  digital  examina- 
tion of  the  vagina  cannot  or  should  not  be  made,  the  mternal  genital 
organs  must  be  examined  per  rectum.    This  method  is  most  useful  in 
cono-enital  or  acquired  absence  of  the  vagina,  a  narrow,  shallow  vagina, 
inversion  of  the  uterus,  ^'aginismus,  and  in  virgins  with  an  intact  hymen 
A  rectal  examination  is  of  special  advantage,  not  onl>-  when  the  vagmai 
examination  is  precluded,  but  in  all  lesions  in  the  rectovaginal  space. 
'  The  position  of  the  patient  should  be  the  lithotomy,  knee-elbow 
or  the  Sims.     In  passing  the  finger  into  the  rectum  the  tonicity  ot 
the  sphincter  is  noted.     Fissures,  polyps,  hemorrhoids,  and  new-tor- 
mations  are  detected.     Through  the  anterior  wall  of  the  rectum  are 
felt  the  posterior  vaginal  wall,  the  cervix,  and  part  or  all  ot  the  pos- 
terior surface  of  the  uterus,  the  base  of  the  broad  ligaments,  frequently 
the  tubes  and  ovaries  when  enlarged  and  prolapsed,  and  the  uterosacral 

Fig.  39 


Digital  examination  of  the  rectum. 

ligaments.  Through  the  posterior  wall  of  the  rectum  are  felt  the 
sacrum  and  cocc^-x.  Because  of  the  thinner  and  more  distensible  bowel 
wall,  the  structures  occupying  the  posterior  segment  of  the  uterus  are 
more  easily  reached  through  the  rectum  than  through  the  posterior 
vaginal  vault.  The  cervix  projecting  backward  is  not  to  be  mistaken 
for  the  body  of  the  uterus. 

Ahdominoredal  Examination  {Bimanual).— This  method  is-carried  out 
in  general  as  is  the  abdominovaginal  examination.  In  virgins  with 
an  intact  hymen  it  is  the  method  of  choice.  All  conditions  recog- 
nized by  a  simple  rectal  examination  are  more  clearly  palpated  by 
the  combined  method. 

The  examination  may  be  embarrassed  by  coils  of  intestine  wedged 
into  the  cul-de-sac  of  Douglas.  When  such  difficulties  exist  and  the 
bowels  are  not  adherent,  they  may  be  displaced  by  placing  the  patient 


Fig.  40 


Rectal  examination  with  traction  upon  the  cen-ix  by  a  vulselltun  forceps. 
Fig.  41 


Abdominovaginorectal  examination.     The  right  hand  depresses  the  abdomen,  the  thumb  of  the  left 
hand  is  inserted  into  the  vagina,  and  the  index  finger  into  the  rectum. 


116     EXAMINATION  OF  EXTERNAL  AND  INTERNAL    GENITALIA 

in  the  knee-chest  position.  A  Sims  specuhim  is  inserted  into  the  bowel, 
allowing  the  air  to  rush  in  and  balloon  the  rectum,  when  the  bowel 
will  fall  forward  out  of  the  cul-de-sac.  The  patient  is  then  placed  m 
the  dorsal  position  and  the  examination  continued. 


Fig.  42 


Vesicorectal  examination.     A  sound  is  passed  into  the  bladder  and  the  index  finger  into  the  rectum. 
In  this  manner  the  presence  or  absence  of  the  uterus  is  determined. 


Traction  upon  the  Uterus  in  the  Abdominorectal  Exaimination 
by  a  vulsellum  forceps  will  greatly  facilitate  the  examination  when  the 
uterus  lies  either  too  far  forward  or  too  high  to  be  readily  reached  by 
the  finger  in  the  rectum.  At  the  same  time  pressure  may  be  made  from 
above  downward  and  backward  upon  the  uterus.  The  vulsellum  forceps 
are  held  by  an  assistant  while  the  operator  makes  the  examination. 
No  great  amount  of  force  should  be  applied  to  the  uterus  for  fear  of 

tearing  adhesions.  ^  •       u i 

Ahdominovaginoredal    Emminations. — This   is   a    most    serviceable 

method  of  examination.    ^Yhile  effective,  it  is  unpleasant  to  patient 

and  physician.    The  finger  should  never  be  withdrawn  from  the  vagina 

and  inserted  into  the  rectum  without  cleansing. 

Digital  examination  of  the  bladder,  either  simple  or  combined  ^yith 

vaginal   and  abdominal  methods   (abdominovesical,   abdominovesico- 


PELVIMETRY  117 

vaginal),  will  not  be  considered.     These  methods  have  been  replaced 
by  others  that  are  more  efficient  and  less  objectionable. 

Pelvimetry.— It  is  seldom  that  pelvic  measurements  are  taken  of  a 
gynecological  case.  This  is  but  an  evidence  of  the  illogical  separation 
of  obstetrics  and  gynecology.  Not  a  few  of  the  pelvic  lesions  are  the 
result  of  deformities  of  the  bony  pelvis.  For  a  detailed  description  of 
the  deformities  of  the  pelvis  and  their  measurements,  the  reader  should 
refer  to  text-books  on  obstetrics.  For  practical  purposes  the  measure- 
ments between  the  anterior  superior  spines  of  the  ilium,  between  the 
trochanters,  between  the  widest  points  in  the  crest  of  the  ilium,  and 
Baudelocque's  diameters  are  all  that  are  required. 


CHAPTER  VII 


INSTRUINIENTAI.  EXAMINATION 


Vaginal  Speculum 
VuLSELLUM  Forceps 
Uterine  Dilators 
Uterine  Sound 

Preliminarj''  Procedures 

Indications 

Contraindications 

Dangers 


Uterine  Curet 

Indications 

Contraindications 

Dangers 

Technic 

In  Treatment 
Exploratory  Punctures  and  Inci- 
sions 


Vaginal  Speculum. — For  direct  inspection  of  the  vagina  the  speculum 
is  used  both  in  diagnosis  and  treatment.  For  diagnostic  purposes  it 
has  a  limited  field  of  usefulness;  digital  exploration  will  alone  serve 
the  purpose  in  a  large  proportion  of  cases. 

The  lithotomy  position  is  the  one  of  choice.  The  rectum  and  bladder 
must  be  emptied.  Before  introducing  the  speculum  a  digital  examina- 
tion of  the  vagina  should  be  made  to  locate  the  cervix  for  the  purpose 
of  knowing  the  proper  direction  in  which  to  introduce  the  speculum 
in  exposing  the  cervix. 

The  varieties  of  specula  in  common  use  are  the  Sims,  Simons,  bivalve, 
and  tubular. 

Sims'  speculum  is  used  with  best  advantage  in  the  lateral  position 
of  Sims.  The  vaginal  outlet  is  spread  open  by  the  thumb  and  index 
finger  of  the  left  hand,  while  the  right  hand  introduces  the  speculum. 
The  blade  is  passed  between  the  fingers  spreading  the  vulva,  and  is 
allowed  to  glide  over  the  perineum  into  the  vault  of  the  vagina. 
With  the  placing  of  the  speculum  the  air  rushes  into  the  vagina  and 
balloons  it.  In  this  manner  a  direct  inspection  of  the  vaginal  mucosa 
is  made  possible.  Firm  and  steady  traction  is  made  backward  upon 
the  perineum  in  exposing  the  cervix.  The  Sims  speculum  was  originally 
used  in  the  knee-elbow  position,  but  is  now  almost  invariably  used  in 
the  Sims  or  left  lateral  posture. 

When  the  vagina  is  deep  and  the  walls  relaxed,  in  addition  to  the 
speculum,  it  is  essential  to  use  some  sort  of  a  depressor  with  which 
to  expose  the  cervix  by  holding  the  Avails  of  the  vagina  apart. 

When  the  cervix  is  directed  backward  and  is  not  readijy  exposed 
to  view  it  may  be  hooked  by  a  tenaculum  and  drawn  forward.  Such 
manipulations  must  only  be  carried  out  under  the  guidance  of  the  eye 
or  finger,  for  fear  of  hooking  the  vaginal  wall  instead  of  the  cervix. 

Simon's  speculum  is  a  device  not  unlike  that  of  Sims',  having  a 
single  spoon  instead  of  two.  It  has  an  advantage  over  Sims'  speculum 
in  that  there  is  no  second  handle  to  interfere  with  the  manipulation 
of  the  instrument. 


VAGINAL  SPECULUM 


119 


A  combination  of  spoons  of  various  shapes  and  sizes  adjusted  to 
separate  handles  has  been  devised  by  Bozeman  and  others. 

For  the  purpose  of  exposing  the  cervix  the  lateral  walls  of  the  vagina 
may  require  retraction. 

The  bivalve  speculum  is  in  general  use,  though  inferior  in  every 
respect  to  the  Sims  and  Simons.  Cusco's  lateral  modification  is  simple 
and  easily  manipulated.  The  instrument  consists  of  two  blades,  taking 
the  form  of  a  beak.  The  articulated  outer  end  is  manipulated  by  a 
screw  which  spreads  the  valves  to  an  acute  angle.  It  is  closed  and 
inserted  by  its  smaller  diameter,  and  when  inserted  the  instrument  is 

Fig.  43 


Insertion  of  the  bivalve  speculum.     Labia  held  apart  by  the  fingers  of  the  left  hand. 

turned  so  that  the  screw  points  toward  the  perineum.  As  the  blades 
are  separated  they  distend  the  vagina,  and  the  cervLx  engages 
between  the  blades.'  The  great  objection  to  this  instrument  is  that  the 
anterior  and  posterior  walls  of  the  vagina  are  obscured  by  the  blades, 
and  the  traction  upon  the  vaginal  walls  separates  the  lips  of  the  cervix 
to  an  unnatural  degree.  The  one  great  advantage  is  the  fact  that  it  is 
a  self-retaining  speculum,  requiring  no  assistant  to  hold  it. 

In  withdrawing  the  instrument  care  must  be  exercised  for  fear  of 
catching  folds  of  the  mucous  membrane;  the  instrument  must  be 
withdrawn  slowly  and  the  screw  gradually  loosened  as  the  speculum 
is  retracted. 


120 


INSTRUMENT  A  L  EX  A  MINA  TION 


The  tubular  speculum  is  seldom  used.  It  is  made  of  metal,  wood, 
celluloid,  glass,  or  vulcanite,  and  may  be  introduced  in  the  lithotomy, 
knee-chest,  or  vSims'  position.  It  can  only  expose  the  cervix,  and  this 
is  done  with  difficulty. 

The  self -retaining-  speculum,  composed  of  a  spoon-like  blade  and  a 
weighted  handle,  will  be  found  of  the  greatest  service  in  making  an 
exploratory  curettage  and  in  excising  pieces  from  the  cervix. 

Currier's  weighted  self-retaining  speculum  with  two  adjustable 
blades  is  an  admirable  device. 


Inspection  of  the  cervix  by  artificial  light  (through  a  bivalve  speculum.) 

Too  much  emphasis  cannot  be  placed  upon  the  necessity  for  surgical 
cleanliness  in  the  use  of  vaginal  specula. 

Some  operators  who  scrupulously  sterilize  all  instruments  to  be 
introduced  into  the  uterus  carelessly  use  a  speculum  after  little  or  no 
cleansing.    Gonorrheal  infection  ma}-  be  transmitted  in  this  manner. 

To  fail  to  sterilize  the  vaginal  speculum  before  using  is  criminal 
negligence. 

Vulsellum  Forceps.— Traction  upon  the  cervix  is  made  with  the 
vulsellum  forceps.  When  the  uterus  and  its  attachments  are  in  a  normal 
position  the  cervix  can  be  drawn  almost  to  the  vulvar  outlet.  Little 
or  no  pain  is  caused  by  the  grasp  of  the  forceps  upon  the  cervix. 


UTERINE  DILATORS  121 

A  vaginal  speculum  need  not  necessarily  be  used  in  grasping  the 
cervix  with  the  vulsellum  forceps;  the  finger  may  be  used  as  a  guide, 
but  this  procedure  demands  great  caution  and  experience. 

As  an  aid  to  diagnosis  the  vulsellum  forceps  is  used  to  make  traction 
upon  the  uterus,  bringing  it  and  adjoining  structures  within  easier 
reach  of  the  examining  finger  in  the  vagina  or  rectum. 

In  determining  the  relation  of  large  tumors  and  swellings  to  the 

.uterus,  it  is  of  advantage  to  steady  the  uterus  by  making  traction 

downward  upon  the  cervix.     The  forceps  is  held  by  an  assistant  while 

the  examiner  manipulates  the  tumor.     If  tumor  and  uterus  move 

together  there  must  be  an  intimate  connection  between  the  two. 

In  differentiating  an  erosion  from  an  eversion  of  the  cervix  the 
two  lips  of  the  cervix  are  grasped  by  the  vulsellum  forceps  and  the 
lacerated  edges  approximated.  If  the  red  surface  disappears  an  eversion 
is  diagnosticated;  if  there  still  remains  a  red  zone  about  the  external 
OS  an  erosion  must  be  present. 

In  removing  sections  from  the  cervix  for  diagnostic  purposes  the 
cervix  is  grasped  by  the  vulsellum  forceps. 

Forcible  traction  upon  the  cervix  is  not  without  danger.  It  is  pos- 
sible to  rupture  the  peritoneum  and  to  tear  through  adhesions.  Acute 
inflammatory  lesions  of  the  pelvis  are  absolute  contraindications  to 
the  use  of  the  vulsellum  forceps  lest  the  inflammation  be  excited  to 
further  extension.  In  the  pregnant  uterus  severe  hemorrhage  may  be 
brought  on  by  the  application  of  the  forceps. 

In  removing  the  vulsellum  forceps  care  must  be  exercised  for  fear 
of  injuring  the  cervix  or  wounding  the  patient.  Superficial  sutures  of 
catgut  or  a  vaginal  pack  of  iodoform  gauze  may  be  placed  if  hemor- 
rhage is  severe. 

Uterine  Dilators. — For  the  purpose  of  exploring  the  uterine  cavity 
with  the  finger  and  curet  the  cervix  must  be  dilated.  Hegar's  or 
Kelly's  dilators  are  recommended  for  general  use.  By  them  the  cervix 
is  symmetrically  dilated,  with  a  minimum  amount  of  trauma. 

The  vaginal  speculum  should  always  be  used  to  expose  the  cervix. 
The  anterior  lip  of  the  cervix  is  grasped  by  a  vulsellum  forceps.  The 
dilators  are  sterilized  by  boiling,  and  lubricated  with  sterilized  glycerin 
or  boroglycerin.  Beginning  with  a  size  that  can  easily  be  passed  through 
the  cervical  canal,  one  after  another  of  the  sounds  is  passed  until  the 
cervix  will  admit  the  index  finger. 

The  utmost  care  must  be  exercised  in  passing  the  dilators  for  fear 
of  losing  control  of  the  instrument  and  accidentally  forcing  it  through 
the  uterine  wall.  To  eliminate  this  danger  the  depth  and  direction 
of  the  uterus  should  first  be  ascertained  by  the  sound.  The  dilators 
are  then  grasped  by  the  thumb  and  index  finger  at  a  point  about  one 
inch  short  of  the  length  of  the  uterus. 

Instruments  of  divulsion,  such  as  Palmer's,  Goodell's,  and  Ellinger's, 
are  commonly  used  in  America.  Only  moderate  force  should  be  applied 
in  dilating  with  these  instruments  for  fear  of  tearing  the  cervix.  They 
do  not  find  favor  in  Europe  because  of  this  frequent  accident. 


122 


INSTRUMENTA  L  EX  A  MINA  TION 


Tents  are  now  seldom  used.  They  are  not  only  slow  and  uncertain 
in  their  action,  but  are  a  source  of  danger  from  infection.  They  are 
made  of  sea-tangle,  sponge,  and  tupelo. 


Fig.  45 


Laminaria  tent.     Dilatation  of  the  cervix  with  a  laminaria  tent. 
Fig.  46 


Cervix  dilated  with  a  Hegar  bougie 

Uterine  Sound.— Aetius  speaks  of  using  the  sound  to  measure  the 
length  of  the  vagina.  Sir  James  Y.  Simpson  introduced  the  modern 
sound  as  a  material  aid  in  the  diagnosis  of  lesions  involving  the  uterus. 


UTERINE  SOUND 


123 


Fig.  47 


Simpson  does  not  deny  that  the  sound  was  used  for  exploration  and 
measurements  of  the  uterus  long  before  his  time.     Certain  it  is  that 
Wierus  used  the  sound  for  like  purposes  as  early  as  1637.    Beginning 
with  the  indorsement  of  Simpson  and  up  to  the  present 
time,  the  sound  has  been  used  too  freely  and  not 
without  harm.     Since  the  bimanual  method  of  ex- 
amination has  been  largely  practised,  the  use  of  the 
sound  has  been  materially  restricted.    It  is  seldom 
necessary  to  pass  the  sound  in  the  consultation  room. 
The  bimanual  examination  will  usually  suffice. 

In  the  construction  of  a  uterine  sound  there  are 
certain  requirements.  This  instrument  should  be 
made  of  a  flexible  metal,  preferably  of  copper,  and 
nickel  plated;  the  distal  end  should  be  rounded  and 
knob-like;  the  handle  should  be  flat  and  grooved  on 
one  side  only.  Beginning  two  and  one-half  inches 
from  the  distal  end  the  sound  should  be  graduated 
every  half-inch  for  the  purpose  of  measuring  the 
depth  of  the  uterine  cavity. 

Preliminary  Procedures. — Before  the  sound  is  passed 
certain  precautionary  measures  are  necessary.  First, 
there  must  be  surgical  cleanliness  in  the  preparation 
of  the  field  of  operation,  the  instruments,  and  the 
hands  of  the  operator.  Second,  a  bimanual  exami- 
nation should  be  made  to  determine,  if  possible,  the 
position  of  the  uterus.  By  adhering  to  these  pre- 
liminary precautions  the  dangers  of  infection  and 
perforation  are  minimized.  The  most  convenient 
position  is  the  lithotomy,  though  it  is  possible  to 
introduce  the  sound  with  the  patient  in  the  lateral  or 
knee-chest  position. 

Indications  for  the  Use.  —  Esiimaiing  the  Depth  of 
the  Uterine  Cavity. — The  depth  of  the  uterine  cavity  is 
accurately  measured  by  the  sound.  Its  average  nor- 
mal depth  is  two  and  a  half  inches  in  a  nullipara 
of  mature  years,  and  this  is  increased  about  one-half 
inch  in  the  multipara. 

(a)  The  depth  of  the  uterine  cavity  is  lessened 
in  acquired  and  congenital  atrophy,  atresia  of  the 
uterus,  inversion  of  the  fundus,  and  in  new-forma- 
tions encroaching  upon  the  cavity  of  the  uterus. 

(6)  The  depth  of  the  uterine  cavity  is  increased 
in  pregnancy,  subinvolution,  elongation  of  the  cervix, 
endometritis,  metritis,  and  newgrowths  of  the  uterus. 

The  Direction  of  the  Uterine  Canal. — This  is  often  changed  from  the 
normal  by  newgrowths  in  and  about  the  uterus,  by  senile  involution, 
by  inflammatory  contraction,  and  by  displacements  of  the  uterus  from 
whatever  cause.     As  stated  above,  it  is  always  wise  to  precede  the 


Simpson's  graduated 
sound. 


124 


INSTRUMENTAL  EXAMINATION 

Fig.  48 


First  step.     The  sound  is  guided  to  the  external  os  along  the  palmar  -  i::  ;■   ■  >  i  t 
speculum  is  used.      The  patient  is  in  the  dorsal  position. 


' I'x  tiugiT  uF  the 


Fig.  49 


Second  step.     The  sound  is  passed  slowly  into  the  uterine  ca\dty.     The  direction  taken  by  the 
sound  is  carefully  noted.     The  patient  is  in  the  dorsal  position. 


UTERINE  SOUND  125 

passage  of  the  sound  by  a  preliminary  bimanual  examination.  If  the 
relation  of  the  body  to  the  cervix  is  determined,  the  sound  is  curved 
at  the  proper  angle  before  it  is  introduced.  By  so  doing  there  is  less 
danger  of  puncturing  the  uterus. 

Stenosis  and  Atresia  of  the  Uterine  Canal. — These  lesions  can  be 
definitely  determined  by  the  sound.  Apparent  stenosis  at  the  point 
of  flexion  is  often  made  to  disappear  by  traction  upon  the  cervix  with 
vulsellum  forceps. 

Irregularities  of  the  Mucosa. — If  not  too  small  and  soft,  they  may  be 
detected  by  the  sound.  Such  irregularities  are  submucous  fibroids, 
polyps,  malignant  groT\-ths,  and  retained  placental  tissue.  When 
possible  it  is  always  preferable  to  use  the  finger  rather  than  the 
sound. 

The  Thickness  of  the  Uterine  Wall. — By  passing  the  sound  into  the 
uterus  and  having  one  hand  over  the  abdomen  and  the  fingers  of  the 
other  hand  in  the  rectum,  it  is  possible,  under  favorable  conditions,  to 
make  a  fair  estimate  of  the  thickness  of  the  uterine  wall. 

Contra-indications  to  the  Use  of  the  Sound. — Menstruation. — Though 
not  an  absolute  contra-indication,  it  is  better  to  delay  the  procedure 
until  the  intermenstrual  period. 

Pregnancy. — Pregnancy  is  an  absolute  contraindication  to  the  pas- 
sage of  the  sound.  While  the  sound  has  been  passed  into  a  gravid 
uterus  without  interrupting  pregnancy,  it  is  never  justifiable  to  pass 
the  sound  when  there  is  a  possibility  of  pregnancy. 

Malignant  Growths. — ^Malignant  groT\-ths,  while  not  an  absolute 
contraindication,  are  to  be  regarded  as  a  source  of  danger  and  demand 
very  cautious  use  of  the  sound  for  fear  of  exciting  hemorrhage  and 
perforating  the  uterus. 

Acute  Pelvic  Inflammation. — Acute  pelvic  inflammation  is  a  con- 
traindication to  the  use  of  the  sound  as  well  as  to  all  manipulations 
of  the  pelvic  viscera. 

Dangers. — Infection  of  the  Uterus. — This  may  be  caused  either  by 
an  unclean  instrument  or  by  carrying  the  infection  from  the  lower 
genital  tract.  Forcible  and  careless  manipulations  injure  the  delicate 
mucosa,  thereby  producing  an  atrium  for  infection.  Because  of  the 
danger  of  infection  the  custom  of  passing  the  sound  in  the  routine 
office  practice  is  condemned. 

Perforation  of  the  Uterus. — This  accident  may  happen  to  the  most 
cautious  operator.  The  uterine  wall  may  be  so  soft  as  to  ofter  no 
perceptible  resistance  to  the  passage  of  the  sound  into  the  peritoneal 
cavity.  Such  softening  may  be  due  to  infection,  malignant  infiltration, 
or  pregnancy. 

Hemorrhage. — Hemorrhage  may  be  alarming  in  the  case  of  malignant 
growths  of  the  uterus,  hydatid  mole,  and  incomplete  abortion. 

Pelvic  Inflammation. — Pelvic  infiammation  may  be  occasioned  by 
the  passage  of  a  sound  into  the  uterus.  This  is  seldom  the  case  in  the 
absence  of  a  preexisting  infection. 

It  is  a  dangerous  practice  to  test  the  mobility  of  the  uterus  by  means 


126  INSTRUMENTAL  EXAMINATION 

of  the  sound.  The  bimanual  examination,  with  or  without  anesthesia, 
should  afford  all  needed  information,  and  with  far  less  risk. 

Uterine  Curet. — The  fact  that  the  uterine  curet  is  universally  used 
speaks  for  its  utility;  but,  as  with  many  of  the  great  and  useful  things 
of  life,  it  is  also  capable  of  harm  in  the  hands  of  the  incompetent. 

The  use  and  abuse  of  the  uterine  curet  is  a  subject  that  should  engage 
the  careful  consideration  of  the  general  practitioner  far  more  than 
many  of  the  more  pretentious  problems  in  the  treatment  of  diseases 
of  women,  because  the  curet  is  the  most  used  and  the  most  abused 
instrument  in  the  armamentarium  of  the  gynecologist,  and,  the  author 
might  add,  of  the  general  practitioner  as  well. 

Fig,  50 


Blake's  curet. 
Fig.  51 


Boldt's  double  curet. 

Indications. — The  indications  for  the  use  of  the  uterine  curet  in  the 
diagnosis  of  the  diseases  of  women  are  as  follows: 

The  uterine  curet  in  diagnosis  may  be  used  in  any  of  the  lesions 
within  the  uterine  cavity  and  involving  the  endometrium. 

Endometritis.  First  in  order  of  clinical  importance  and  frequency  is 
endometritis.  An  excessive  menstrual  flow  and  a  so-called  leucorrheal 
discharge  from  the  uterus,  together  with  a  history  of  infection, 
generally  suffice  for  a  clinical  diagnosis  of  endometritis;  but  a  posi- 
tive diagnosis — one  that  amounts  to  a  scientific  certainty — can  only 
be  made  by  a  microscopic  examination  of  scrapings  removed  by 
the  curet.  All  of  the  clinical  signs  of  endometritis  may  be  present 
without  inflammator}^  changes  in  the  endometrium,  and,  on  the  other 
hand,  endometritis  ma}'  be  present  to  a  marked  degree  in  the  absence 
of  any  clinical  evidence.  It  is  never  justifiable  to  curet  the  uterus  for 
the  purpose  of  differentiating  between  the  various  anatomical  forms 
of  endometritis,  but  rather  to  determine  the  fact  of  endometritis  and 
to  exclude  other  possible  lesions,  such  as  *  retained  placental  tissue 
and  carcinoma.  It  is  a  matter  of  little  concern  whether  the  lesion  is 
a  hypertrophic  or  a  hyperplastic,  a  fungous  or  a  polypoid  endometritis. 
It  is  the  possibiHty  of  the  presence  of  endometritis  and  not  'the  ques- 
tion of  the  particular  anatomical  variety  that  is  of  practical  clinical 
importance. 

Retained  Products  of  Conception. — These  may  remain  attached  to 
the  uterus  for  years,  giving  rise  to  hemorrhage  and  leucorrhea,  the 
cause  of  which  can  only  be  demonstrated  by  exploring  the  uterine 
cavity.     In  all  such  cases  the  finger,  if  possible,  should  be  used  in 


CONTRAINDICATIONS  127 

locating  and  removing  the  retained  fetal  tissue.  Shortly  after  abortion 
and  labor,  curetting  is  rarely  justifiable  because  of  the  dangers  involved. 
The  author's  preference  is  for  the  Emmet  curet  forceps  as  a  substitute 
for  the  usual  form  of  curet. 

Fig.  52 


Emmet  curet-forceps. 

Submucous  Fibroid. — The  firm,  rounded  bulging  of  a  submucous 
fibroid  is  sometimes  demonstrated  by  means  of  the  curet. 

Maligncmt  Growths. — Malignant  growths  of  the  endometrium  can 
only  be  diagnosticated  in  the  early  stage  by  microscopic  examinations 
of  scrapings.  There  may  be  no  symptoms,  or  merely  those  common 
to  endometritis,  and  this  is  even  possible  in  cases  far  advanced.  In 
the  author's  experience  the  systematic  examination  of  uterine  scrapings 
has  frequently  brought  to  light  an  unsuspected  malignant  growth, 
and  that  which  has  passed  clinically  for  malignancy  has  been  demon- 
strated to  be  endometritis  or  retained  placental  tissue. 

Syncytioma  malignum — i.  e.,  a  malignant  degeneration  of  placental 
tissue — is  a  rare  finding,  but  because  of  its  rapid  spread  and  fatal 
issue  an  early  diagnosis  is  imperative.  When  an  unaccountable  hemor- 
rhage from  the  uterus  occurs  weeks  or  months  after  labor  or  abortion, 
and  particularly  after  the  expulsion  of  a  hydatid  mole,  an  exploratory 
curettage  is  demanded,  and  a  microscopic  examination  should  be  made 
in  view  of  the  possible  finding  of  malignant  changes  in  the  placental 
remains. 

There  is  no  more  important  and  certainly  no  more  satisfactory 
procedure  in  all  the  range  of  diagnosis  than  the  differential  diagnosis 
of  uterine  scrapings.  A  sharp  line  cannot  always  be  drawn  between 
the  benign  and  tlie  malignant,  but  in  the  hands  of  a  competent  observer 
such  failures  are  unusual. 

In  the  diagnosis  of  ectopic  pregnancy  it  is  sometimes  advisable  to 
curet  the  uterus  to  determine  the  presence  of  decidual  tissue.  Great 
caution  must  be  exercised  for  fear  of  rupturing  the  gestation  sac. 

Contra-indications. — Menstruation. — Menstruation  is  not  an  absolute 
contra-indication,  but  it  is  seldom  that  the  procedure  cannot  be  delayed 
until  the  menstrual  period  Is  passed. 

Pregnancy. — The  possibility  of  pregnancy  must  be  positively 
excluded.  When  doubt  exists  after  a  thorough  examination  it  is 
always  well  to  await  developments  for  a  month  or  more.  A  good  rule 
to  follow  is  to  never  use  the  curet  in  cases  of  delaj^ed  menstruation 
when  pregnancy  is  at  all  possible. 


128  INSTRVMEXTAL   EXAMIXATIOX 

Acute  and  Subacuie  Pelvic  Inflammations. — These  are  contraindica- 
tions because  of  the  danger  of  extending  the  infection.  It  is  always 
wise  to  wait  until  the  pelvic  inflammation  has  subsided  before  curetting. 
Distended  tubes  and  ovaries  are  liable  to  rupture.  Xo  harm  is  likely 
to  result  if  the  contained  matter  is  serum,  but  if  pus  escapes  the  con- 
sequences may  be  disastrous. 

Dangers. — The  dangers  involved  in  curettage  are  by  no  means  trivial. 
The  curet  is  a  formidable  instrument,  and  curettage  is  not  to  be  regarded 
as  a  minor  operation  and  without  attending  dangers. 

Septic  Infections. — ^As  with  all  operations,  there  is  the  risk  of  septic 
infection  through  a  wounded  surface.  The  likelihood  of  infection 
is  not  great  when  the  uterus  is  firmly  contracted;  but  in  the  puerperal 
uterus,  with  large  venous  sinuses  and  possible  infection  already  existing 
therein,  all  the  conditions  are  present  which  favor  a  woimd  infection. 

Hemorrhage. — Hemorrhage  is  an  unlooked-for  complication,  yet  in 
puerperal  and  malignant  cases  the  loss  of  blood  may  be  alarming  and 
fatal. 

Inflammatory  Exacerbations. — The  danger  of  exciting  an  acute  ex- 
acerbation of  a  preexisting  pelvic  inflammation  is  always  imminent. 

Perforation. — Perforation  of  the  uterus  by  the  curet  is  an  accident 
that  may  happen  to  the  most  skilled  and  cautious  surgeon.  The  author 
ventures  the  assertion  that  not  an  operator  of  large  experience  has 
escaped  this  misfortune.  The  statements  frequently  made  that  the  per- 
foration is  of  little  consequence  are  not  substantiated.  In  a  puerperal 
infected  uterus  the  uterine  wall  may  offer  no  more  resistance  to  the 
curet  than  woidd  blotting  paper;  the  instrimient  passes  through  the 
wall,  apparently  meeting  no  resistance.  In  dealing  with  a  puerperal 
uterus  the  only  safeguard  lies  in  discarding  the  curet,  both  the  dull  and 
the  sharp.  The  fingers,  placental  forceps,  and  douche  are  all  sufficient, 
save  in  very  exceptional  cases.  Not  only  is  the  finger  less  likely  to 
perforate  the  uterus,  but  by  the  finger  the  placental  site  is  located  and 
the  adherent  placenta  remo^'ed,  leaving  the  remaining  uterine  surface 
intact,  as  it  should  be.  Nature  has  thrown  out  a  barrier  in  the  decidua 
in  the  form  of  leucoc\'tes  or  phagocytes,  the  so-called  "protective 
zone,"  that  t\i11  resist  the  invasion  of  microorganisms  if  it  is  possible 
for  anything  to  do  so.  The  curet  would  but  tear  away  this  protective 
wall  and  allow  a  direct  invasion  of  the  venous  sinuses  by  the  septic 
organisms. 

Removal  of  Decidua. — The  remo\'al  oi  the  decidua  down  to  the 
musculature  is  a  possible  danger  when  the  curet  is  used.  With  the 
finger  this  accident  will  not  occur.  From  the  decidua  the  new  endome- 
trium is  regenerated,  and  if  completely  scraped  away  there  will  be 
left  in  its  place  a  permanent  scar  surface,  rendering  the  woman  sterile 
and  a  sufferer. 

The  same  result,  though  to  a  lesser  degree,  may  follow  too  vigorous 
scraping  of  the  non-puerperal  uterus.  The  grating  of  the  instrument 
is  a  sign  that  the  mucosa  is  removed  down  to  the  deeper  and  firmer 
layers,  and  it  is  time  to  stop  lest  the  entire  mucosa  be  removed. 


TECHNJC  OF  OPERATION  OF  CURETTAGE 


129 


Technic   of    Operation, — The   following   is   an  outline  of  the  technic 
of  curettage: 

1.  Anesthesia,  preferably  ether  or  nitrous  oxide  and  oxigen. 

2.  Shaving  and  sterilization  of  the  vulva  and  vagina. 

3.  Dilatation  of  the  cervix  with  Hegar's  bougies  or  an  instrument 
of  divulsion. 

Fig.  53 


Graduated  bougies  are  used  for  the  dilatation  of  the  cervix.     This  method  is  preferable  to  that 

shown  in  Fig.  54. 

4.  Cautious  introduction  of  a  curet  to  one  of  the  uterine  horns  and 
deliberately  sweeping  downward  as  far  as  the  internal  os.  Passing  by 
successive  sweeps  along  the  posterior  wall  to  the  opposite  horn,  then 
to  the  side  and  in  front  to  the  original  point  of  attack,  making  sure 
that  no  furrows  or  patches  are  left  by  again  going  over  the  surface  in  a 
similar  manner.  All  upward  movements  of  the  curet  should  be  per- 
formed with  caution  for  fear  of  perforating  the  uterus. 

5.  As  a  routine  practice  the  author  would  recommend  swabbing 
the  uterus  with  full  strength  formalin. 

6.  No  uterine  pack  is  recommended  unless  the  uterus  is  relaxed 
and  bleeding  freely.  A  sterile  vaginal  tampon  should  be  inserted 
against  the  cervix  for  twenty-four  hours,  then  removed,  and  1  per 
cent,  lysol  douches  or  formalin  (1  to  2000)  should  be  given  daily  for  a 
week. 

7.  Rest  in  bed  should  be  enjoined  for  a  period  of  four  or  more  days. 
9 


130 


1 NS  TR  UMEN  TA  L  EX  A  MINA  TION 


8.  No  escharotics  should  be  used.  The  sharp  curet  should  be  em- 
ployed in  all  cases,  with  the  exception  of  a  puerperal  uterus,  which 
should  never  be  scraped.     (See  Figs.  53  to  56.) 


Fig.  54 


Cen'ix  is  exposed  by  a  self-retaining  speculum  and  grasped  at  its  anterior  lip  by  a  vulseUum  forceps. 
Traction  is  made  upon  the  cervix  as  it  is  dilated  by  an  instrument  of  divulsion.  Patient  in  dorsal 
position. 


The  Uterine  Curet  in  Treatment. — There  is  no  instrument  so  universally 
misused  as  the  uterine  curet.  It  has  been  applied  for  the  relief  of 
almost  every  pelvic  disorder,  because  no  accurate  diagnosis  was  made. 
Pelvic  pain,  leucorrhea,  uterine  hemorrhage,  backache,  sterility,  one  and 
all,  have  been  made  the  object  for  the  indiscriminate  use  of  the  curet. 
The  fact  is,  there  is  but  a  limited  field  of  usefulness  for  the  curet  in 
the  treatment  of  diseases  of  women. 

Indications. — Following  are  the  therapeutic  indications: 

Control  of  Uterine  Hemorrhage. — Whatever  the  cause  of  uterine 
hemorrhage  may  be,  whether  it  is  due  to  endometritis,  cancer,  fibroids, 
muscular  insufficiency  of  the  uterus,  polyps,  sarcoma,  syncytioma 
malignum,  etc.,  the  bleeding  can  usually  be  checked  for  a  time  at  least 
by  thorouglily  scraping  the  uterus.  The  control  of  uterine  hemorrhage 
is  the  one  great  therapeutic  function  of  the  curet. 

Leucorrhea. — ^\^Tien  there  is  no  infection  of  the  uterus  the  leucorrheal 
discharges  can  be  controlled  in  part  by  scraping  the  uterus,  but  the 


Fig.  55 


Curettage  of  the  uterus. 
Fig.   .56 


Curetted  surface  is  s-n-abbed  -n-ith  pure  formalin. 


132 


INSTRUMENTAL  EXAMINATION 


opportunity  will  rarely  arise  for  its  use  in  this  particular.  The  uterus 
should-  never  he  curetted  in  the  presence  of  a  purulent  discharge,  because 
the  scraping  of  an  infected  uterus  leads  to  extension  of  the  infection  to  the 
deeper  structures  in  the  uterine  wall  and  to  the  tubes.  Because  of  the 
great  importance  of  this  dictum  the  author  repeats,  Never  curette  an 
infected  uterus! 

Inoperable  Cancer  of  the  Uterus. — When  the  disease  has  gone  beyond 
hope  of  radical  cure  the  hemorrhages  and  other  discharges  may  be 
controlled  for  a  time  by  scraping  away  all  friable  tissue. 

Exploratory  Punctures  and  Incisions. — An  exploratory  puncture  is 
occasionally  resorted  to  for  the  purpose  of  completing  the  diagnosis. 
When  a  conjoined  examination  fails  to  determine  the  nature  of  a  pelvic 
tumor,  aspiration  is  an  essential  aid  to  the  diagnosis.  Collections  of 
blood,  pus,  and  serum  in  the  tubes,  ovaries,  and  pelvic  tissues  often 
cannot  be  diagnosticated  with  certainty  until  the  contents  are  procured 
either  by  aspiration  or  by  incision.  Furthermore,  the  character  of  the 
obtained  fluid  may  not  be  recognized  until  submitted  to  a  chemical, 
microscopic,  and  bacteriological  examination.  It  is  a  growing  con- 
viction that  an  exploratory  incision  afi'ords  better  results  and  is  less 
dangerous  than  is  aspiration.  This  is  particularly  true  of  abdominal 
explorations.  It  is  a  matter  of  common  experience  that  pus  and  blood 
cannot  always  be  withdrawn  from  the  pelvis  through  an  aspirating 
needle. 


Fig.  57 


Exploratory  syringe. 


The  instrument  and  field  of  operation  must  be  rendered  perfectly 
sterile.  When  surgical  principles  are  carried  out  no  harm  should 
follow  either  procedure.  Exploratory  incisions  are  of  value  not  only 
in  determining  the  character  of  the  contained  fluids  in  the  pelvis,  but 
the  procedure  has  a  much  wider  range  of  usefulness.  Indeed,  it  may 
he  truly  said  that  every  abdominal  incision  is  in  a  sense  exploratory. 
The  abdomiiial  surgeon  very  often  encounters  unsuspected  groioths  and 
adhesions,  and,  for  this  reason,  one  who  is  not  master  of  any  condition 
that  may  unexpectedly  arise,  should  not  undertake  to  open  the  abdominal 
cavity. 


CHAPTER   VIII 

MICROSCOPIC  EXAMINATION  OF  SCRAPINGS  AND 

EXCISED  PARTS— DIAGNOSIS  OF  EXPELLED 

MEMBRANES  FROM  THE  UTERUS 


MICROSCOPIC  EXAMINATION  OF  SCRAPINGS  AND  EXCISED 

PARTS 


Removal    op    Uterine    Tissue    for 

Diagnostic  Purposes 
Test  Excision  from  the  Cervix 
Test  Curettage  of  the  Uterus 
Frozen  Specimens  of  Excised  Pieces 

AND  Scrapings 


Fixing  the  Specimens 
Hardening  and  Embedding 
Method  of  Staining  and  Mounting 

Sections 
Inspection    of    Uterus    after    Re- 
moval 


The  microscope  is  indispensable  in  the  diagnosis  of  diseases  of 
women.  The  microscopic  examination  of  scrapings  and  excised  pieces 
constitutes  one  of  the  most  important  and  gratifying  means  of  deter- 
mining the  character  of  lesions  involving  the  cervix  and  endometrium. 

Bimanual  examination  alone  will  determine  many  of  the  affections 
of  the  pelvic  viscera;  inspection  of  the  vagina  and  vaginal  portion  of 
the  cervix  through  a  speculum  will  afford  much  information;  direct 
palpation  of  the  cervical  canal  and  cavity  of  the  uterus  will  add  much 
knowledge  of  the  extent  and  character  of  the  lesions  involving  these 
surfaces;  the  clinical  symptoms  are  important  in  the  consideration, 
but  a  positive  diagnosis,  one  that  admits  of  no  reasonable  doubt,  is 
often  reserved  until  a  microscopic  examination  of  scrapings  and  excised 
pieces  has  been  made. 

Very  often  the  microscope  serves  to  verify  a  clinical  diagnosis,  but 
in  not  a  few  cases  a  previously  unsuspected  condition  is  brought  to 
light  by  a  microscopic  examination  of  scrapings  from  the  endometrium 
and  excised  pieces  from  the  vaginal  portion  of  the  cervix. 

The  author  does  not  claim  that  the  microscope  is  an  infallible 
means  of  making  a  diagnosis.  These  are  cases  in  which  the  diagnosis 
remains  in  question  after  all  means — the  microscope  included — have 
been  exhausted. 

When  a  clinical  diagnosis  of  cancer  is  made  the  suspected  tissue 
should  not  be  scraped  unless  preparations  are  made  for  a  radical 
operation.  This  rule  should  be  enforced  because  of  the  danger  of 
disseminating  a  cancerous  growth  by  means  of  the  curet. 

Removal  of  Uterine  Tissue  for  Diagnostic  Purposes. — In  all  cases, 
unless  contraindicated,  a  general  anesthetic  is  advisable.  Cocaine 
may  be  used  as  a  local  anesthetic  in  excising  pieces  from  the  cervix. 


134  MICROSCOPIC  EXAMIXATIOX  OF  SCRAPIXGS 

When  the  tissue  is  soft  and  friable,  as  in  carcinoma,  no  local  or  general 
anesthetic  may  be  required. 

It  is  not  necessary  to  shave  the  vuh'a.  Init  by  ^(Tubbing  and  douching 
the  field  of  operation  is  made  clean. 

The  position  assumed  by  the  patient  may  be  the  Sims  or  lithotomy. 
If  the  former,  the  Sims  or  Simon  speculum  is  used;  if  the  latter, 
the  Simon  or  self-retaining  speculum  is  preferred.  The  self-retaining 
speculum  is  especially  advantageous  because  no  assistant  is  needed. 

Test  Excision  from  the  Cervix. — ^After  grasping  the  anterior  iip 
of  the  cervix  by  the  vulsellum  forceps  a  small  wedge  is  cut  from  the 
cervix  by  angular  scissors.  In  selecting  a  portion  for  excision  an 
effort  should  be  made  to  include  in  the  removed  piece  a  part  of  the 
healthy  together  with  the  diseased  tissue  for  the  purpose  of  studying 
the  transition  stages. 

Hemorrhage  is  controlled  by  a  gauze  pack,  or,  when  necessary,  by 
the  placing  of  absorbable  sutures. 

Test  Curettage  of  the  Uterus. — The  cervix  is  dilated  sufficiently 
to  admit  a  moderate-sized  curet.  The  instrument  is  passed,  under 
control  of  the  eye,  by  the  aid  of  a  Sims  or  Simon  speculum.  The 
patient  is  in  the  Sims  or  lithotomy  position.  In  order  that  no  portion 
of  the  endometrium  escape  the  curet,  the  uterus  should  be  scraped 
systematically  and  thoroughly,  beginning  at  one  horn  and  sweeping 
deliberately  down  to  the  internal  os,  passing  in  this  manner  over  the 
entire  inner  surface  of  the  uterus,  taking  care  that  no  portion  of  the 
endometrium  be  missed.  Before  the  blood  has  time  to  coagulate 
firmly  the  scrapings  are  first  washed  in  cold  running  water  and  then 
removed  to  a  4  per  cent,  solution  of  formalin.  Allowing  them  to  lie 
long  in  water  causes  maceration.  All  particles  in  the  scrapings  are 
to  be  carefully  preserved,  so  that  if  necessary  the  entire  specimen  may 
be  examined. 

Frozen  Specimens  of  Excised  Pieces  and  Scrapings. — When  an 
immediate  diagnosis  is  required  the  freezing  method  may  be  employed 
with  fairly  satisfactory  results.  It  occasionally  happens  that  the 
examination  of  excised  pieces  and  scrapings  will  determine  the  question 
of  a  more  radical  procedure.  If  for  reason  of  expediency  or  added  risk 
from  a  second  anesthetic  it  becomes  necessary  to  proceed  without 
delay,  frozen  sections  may  be  prepared  and  diagnosticated  while  the 
patient  is  being  prepared  for  a  radical  operation.  Xot  more  than 
twenty  minutes  are  required  for  the  examination. 

The  following  is  the  method  employed  in  Johns  Hopkins  Hospital 
by  Cullen: 

(a)  Place  the  frozen  section  in  5  per  cent,  aqueous  solution  of  formalin 
for  from  three  to  five  minutes. 

(&)  Leave  in  50  per  cent,  alcohol  one  minute. 

(c)  In  absolute  alcohol  one  minute. 

(d)  Wash  out  in  water. 

(e)  Stain  in  hematoxj-lin  two  minutes. 
(/)  Decolorize  in  acid  alcohol. 


FROZEN  SPECIMENS  OF  EXCISED  PIECES  AND  SCRAPINGS     135 

(({)  Rinse  in  water. 
(A)  Stain  with  eosin. 
(^)  Transfer  to  95  per  cent,  alcohol. 

(j)  Pass  through  absolute  alcohol,  then  through  creosote  or  oil  of 
cloves,  and  mount  in  Canada  balsam. 

Fig.  58 


Bardeen  CO2  freezing  microtome.  This  microtome  is  an  improved  pattern  after  designs  by  Professor 
C.  R.  Bardeen,  of  Johns  Hopkins  University,  and  is  a  most  excellent  instrument  for  regular  patho- 
logical and  other  demonstrations.  It  is  indispensable  for  clinical  work  when  stained  sections  of  morbid 
tissues  are  required  within  a  few  minutes  of  the  beginning  of  an  operation  in  order  that  the  surgeon 
may  determine  his  mode  of  procedure.  It  freezes  almost  instantaneously  regardless  of  room,  tempera- 
ture, or  humidity,  and  at  very  small  expense.  The  temperature  of  the  object  to  be  frozen  is,  within 
limits,  under  the  control  of  the  operator.  The  freezing  chamber  contains  a  spiral  passage  through 
which  the  expanding  CO2  passes,  securing  the  maximum  freezing  power.  The  knife  sUdes  on  glass 
guides.    The  finest  feed  is  twenty  microns.    The  microtome  may  be  attached  directly  to  a  CO2  cylinder. 


While  the  freezing  method  has  an  important  place  in  connection 
with  the  operating  room,  the  sections  are  not  eminently  satisfactory, 
for  the  reason  that  only  small  sections  can  be  made  and  differentiating 
stains  cannot  be  used.  When  an  immediate  diagnosis  is  not  required 
(and  this  is  true  in  the  majority  of  instances)  the  celloidin  or  paraffin 
methods  are  preferred. 


136 


MICROSCOPIC  EXAMINATION  OF  SCRAPINGS 


Fixing  the  Specimens. — Zenker's  Fluid. — Zenker's  fluid  (IMiiller's 
fluid,  100  per  cent.;  bichloride,  5  per  cent.,  and,  shortly  before  using, 
the  addition  of  5  per  cent,  of  glacial  acetic  acid)  is  an  excellent  fixing 
fluid,  preserving  the  blood  in  its  natural  color.  After  fixing  in  Zenker's 
for  twenty-four  hours  the  section  is  placed  in  cold  running  water  for 
twenty-four  hours  or  in  a  weak  iodine  solution  for  a  like  time.  The 
section  is  then  ready  for  hardening  in  alcohol.  No  better  fixing  fluid 
can  be  used  when  time  will  permit.  It  is  often  well  to  place  the 
entire  uterus  in  Zenker's  fluid  for  a  week  or  more  before  cutting 
sections  from  it. 

Fig.  59 


Ether  or  rhigolene  freezing  attachment.  This  attachnaent  consists  of  a  cylindrical  freezing  stage 
upon  which  the  object  to  be  frozen  is  placed  and  against  which  a  very  fine  spray  of  ether  or  rhigolene 
as  desired  is  projected  by  a  delicate  atomizer  operated  by  the  bulb  air-pump  shown  in  the  illustration. 
The  rapid  evaporation  of  the  fluid  abstracts  sufficient  heat  from  the  object  to  freeze  it  in  a  short  time. 
There  is  always,  however,  an  excess  of  fluid  which  does  not  evaporate,  and  this  is  drained  back  into 
a  bottle  and  used  again.  This  freezer  is  applicable  to  the  automatic  laboratory,  medium  laboratory, 
student,  table,  and  demonstration  microtomes. 


Alcohol. — Alcohol  as  a  fixing  agent  is  objectionable  because  of  the 
shrinkage  of  the  tissues.  \\Tien  it  is  desired  to  examine  for  micro- 
organisms, alcohol  is  of  special  value. 

Formalin, — Formalin  may  be  used  in  a  2  to  4  per  cent,  solution. 
It  is  objected  to  because  of  the  difficulty  in  cutting  the  musculature. 

Hardening  and  Embedding. — When  it  is  desired  to  prepare  the 
section  hurriedly,  a  small  piece  is  placed  immediately  in  ^absolute 
alcohol  and  changed  three  or  four  times  in  twenty-four  to  thirty-six 
hours,  when  it  is  ready  for  embedding. 

When  an  additional  day  or  two  can  be  taken,  better  sections  are 
made  by  running  the  pieces  through  successive  strengths  of  alcohol, 
changing  every  two  to  twelve  hours  through  70,  80,  and  90  per  cent, 
and  absolute  alcohol. 

It  is  now  necessary  to  embed  the  section  in  a  substance  that  will 


HARDENING  AND  EMBEDDING 


137 


permeate  the  tissue,  fill  up  all  spaces,  and  give  support  to  the  section 
while  being  cut  and  mounted. 

The  embedding  of  a  specimen  in  celloidin  follows  upon  the  harden- 
ing process.  For  general  purposes  the  celloidin  method  is  preferred. 
From  absolute  alcohol  the  section  is  placed  in  equal  parts  of  sulphuric 
ether  and  absolute  alcohol  for  from  six  to  twenty-four  hours,  depending 
upon  the  size  of  the  section.  Next  the  section  is  transferred  to  a  dilute 
solution  of  celloidin  in  ether  for  from  six  to  twenty-four  hours;  it  is 
then  placed  in  a  thick  solution  of  celloidin  in  ether  for  an  equal  time, 
when  it  is  ready  to  mount  upon  a  cork  for  sectioning. 

After  blocking  the  specimen  on  wood  or  cork  it  is  allowed  to  fix 
firmly  in  the  open  air  or  under  a  bell-jar,  and  is  then  placed  in  70  per 
cent,  alcohol  for  an  hour  or  more.  The  section  is  now  ready  for  cutting 
and  mounting. 


Fig.  60 


The  student  microtome.  This  is  intended  for  individual  and  laboratory  use  when  a  mechanical 
microtome  at  small  cost  is  required.  It  is  extremely  simple,  yet  very  accurate  in  construction.  This 
is  one  of  the  few  models  which  have  remained  practically  unchanged,  showing  that  it  is  adapted  for 
its  work.  The  stand  is  one  solid  piece  of  metal.  The  knife  block  is  as  heavy  as  is  consistent  with  the 
size  of  the  instrument.  The  feed  arrangement  is  carried  in  a  metal  stirrup  attached  permanently  to 
the  front  of  the  stand,  and  consists  of  an  accurately  cut  micrometer  screw  having  a  pitch  of  0.5  mm., 
with  a  graduated  head  divided  to  100  parts,  each  graduation,  therefore,  having  a  value  of  5  microns. 
The  object  clamp  is  adjustable  in  two  planes,  and  can  be  set  for  paraffin  or  celloidin  cutting. 


The  embedding  of  sjjecimens  in  paraffin  is  an  excellent  method  for 
general  laboratory  purposes,  but  is  somewhat  complicated  for  private 
laboratory  use.  When  the  tissues  are  soft  and  small,  as  in  scrapings, 
ideal  sections  are  prepared  by  this  method.  For  serial  sections  no 
other  method  can  be  employed.  After  thoroughly  dehydrating  the 
tissue  the  specimen  is  immersed  in  a  solution  of  zylol  and  paraffin, 
or  in  chloroform  and  paraffin,  for  from  two  to  twenty-four  hours,  and 
is  kept  at  a  uniform  temperature  of  37°  C.  Next  the  specimen  is  im- 
mersed in  melted  paraffin  for  a  like  time  and  kept  at  a  temperature 


138 


MICROSCOPIC  EXAMIXATIOX  OF  SCRAPINGS 


of  4S°  to  50°  C.  It  is  then  removed  to  a  cool  place  and  is  quickly 
solidified  in  the  paraffin,  after  which  it  is  blocked  out  with  a  knife  and 
mounted  on  a  cork  for  cutting. 

Method  of  Staining  and  Mounting  Sections. — Celloidin  Sections. — 
For  all  practical  purposes  the  hematoxylin-eosin  stain  is  most  satis- 
factory. After  cutting  the  sections  and  immersing  them  in  water  for 
a  few  moments  the  following  method  is  adopted: 


Lines  of  incision  in  opening  the  uterus  after  hysterectomy. 


1.  Stain  in  hematoxylin  one  to  two  minutes. 

2.  Decolorize  in  acid  alcohol. 

3.  Immerse  in  weak  ammonium-water  until  the  blue  color  returns. 

4.  Immerse  in  water  to  remove  the  ammonium. 

5.  Counter-stain  in  eosin  from  ten  to  thirty  seconds 

6.  Immerse  in  75  per  cent,  alcohol  two  minutes. 

7.  Absolute  alcohol  one  minute. 

8.  Clear  in  creosote  or  oil  of  cloves. 

9.  Mount  in  Canada  balsam. 

Paraffin  Sections.^ — After  cutting  the  sections  they  are  carefully 
transferred  to  a  shallow  basin  of  warm  water,  on  which  they  spread  in 
thin  ribbons.    The  water  must  not  be  hot  enough  to  melt  the  paraffin, 


INSPECTION  OF  THE   UTERUS  AFTER  REMOVAL 


139 


but  merely  sufficiently  so  to  unfold  the  sections  and  spread  them  out 
smoothly.  A  glass  slide  is  held  underneath  the  sections,  and  they  are 
made  to  float  upon  the  slide.  The  slide  is  then  withdrawn  from  the 
water,  the  water  drained  off  from  the  slide,  when  it  is  placed  for  several 
hours  on  the  top  of  an  oven  or  radiator,  where  the  moisture  is  thor- 
oughly driven  from  the  slide  and  the  section  firmly  fixed.  The  paraffin 
is  dissolved  in  zylol  or  cliloroform  (by  which  the  section  is  "cleared"), 
and  from  this  point  on  the  staining  is  carried  out  in  the  usual  manner. 


The  uterine  cavity  exposed. 


Inspection  of  the  Uterus  after  Removal. — In  order  that  a  satisfactory 
examination  may  be  made  of  the  uterus  after  its  removal,  the  operator 
should  handle  and  mutilate  the  specimen  as  little  as  possible.  The 
introduction  of  swabs,  probes,  and  curets  injures  the  endometrium 
and  leads  to  false  observations.  Fig.  61  shows  the  method  of  opening 
the  uterus.  The  body  of  the  uterus  is  grasped  by  the  left  hand.  Two 
incisions  are  made,  as  shown  in  Fig.  61  and  the  uterus  is  spread  open 
in  such  a  manner  that  the  entire  mucosa  will  be  exposed  (Fig.  62). 
Before  the  uterus  is  opened  it  is  always  well  to  fix  it  in  Zenker's  fluid 
for  several  days.  The  structures  are  thereby  less  disturbed  in  their 
relations. 

The  color,  consistency,  outline,  and  measurements  are  all  to  be 
noted  and  recorded.  Foreign  growths  and  abnormalities  are  described 
in  detail. 


140     DIAGNOSIS  OF  EXPELLED  MEMBRANES  FROM  THE  UTERUS 

THE  DIAGNOSIS  OF  EXPELLED  MEMBRANES  FROM  THE 

UTERUS 

The  physician  will  be  called  upon  to  determine  the  nature  of  a  mem- 
brane or  mass  spontaneously  expelled  from  the  uterus.  Here  the 
microscope  is  indispensable  to  a  positive  diagnosis.  It  is  of  prime 
importance  to  determine,  first,  whether  or  not  the  membrane  is  organ- 
ized. If  on  placing  the  membrane  in  cold  water  it  becomes  friable 
and  disintegrates  it  is  unorganized.  Under  the  microscope  a  fibrinous 
structure  is  seen,  in  the  meshes  of  which  are  blood  cells  in  all  stages 
of  disintegration.  Calcareous  concretions  may  be  expelled  sponta- 
neously or  removed  by  the  curet.  They  probably  come  from  calcareous 
deposits  in  mucous  polyps  or  submucous  fibroids. 


Cast  from  uterine  cavity  in  exfoliative  endometritis,  membranous  dysmenorrliea,  natural  size. 

(After  Costa.) 

Of  the  organized  structures  the  following  will  be  considered:  the 
decidua  of  intra-uterine  pregnancy,  the  decidua  of  extra-uterine  preg- 
nancy, the  decidua  of  menstruation,  and  the  vesicles  of  hydatiform 
mole. 

Membranous  Dysmenorrhea  (Exfoliative  Endometritis). — Because 
of  the  occurrence  of  menstruation  accompanied  by  a  discharged  mem- 
brane and  great  pain  the  condition  is  spoken  of  as  membranous  dys- 
menorrhea; but  since  the  discharged  membrane  does  not  resemble  that 
of  the  uterine  mucosa  during  menstruation,  but  does  closely  resemble 
interstitial  exudative  endometritis,  a  better  term  to  employ  would 
be  exfoliative  endometritis.  This  does  not  imply  that  the  lesion  is 
necessarily  inflammatory  in  origin,  inasmuch  as  there  are  no  known 
facts  to  substantiate  such  an  assertion.  Nothing  definite  is  known  of 
the  cause  of  this  lesion. 


MEMBRANOUS  DYSMENORRHEA 


141 


The  first  clinical  observations  were  made  in  1723  by  Morgagni. 
When  the  existence  of  pregnancy  can  be  excluded  beyond  all  possible 
doubt  a  clinical  diagnosis  is  made.  When  there  is  any  possibility 
of  pregnancy  a  positive  diagnosis  can  only  be  made  by  a  microscopic 
examination  of  the  discharged  membrane,  and  even  here  difficulties 
will  arise  because  of  the  presence  of  large  connective-tissue  cells 
resembling  decidual  cells. 


Fig.  64 


Aborted  ovum.    Decidua  and  ovum  complete,    o.  i.,  corresponds  to  the  decidua  situated  at  the 
OS  internum;  t  t,  to  the  decidua  situated  at  the  openings  of  the  tubes.     (Jewett.) 

Macroscopic  Examination. — The  membrane  rarely  appears  as  a  com- 
plete cast  of  the  uterus.  In  form  it  is  triangular,  presenting  an  opening 
at  each  angle — i.  e.,  the  internal  os  and  the  uterine  ends  of  the  Fallopian 
tubes.  The  outer  surface  is  shaggy  and  of  a  dull  gray  color;  it  is  some- 
times overlaid  with  a  coagulum  of  blood.  Opening  the  sac,  nothing 
is  found  within  to  suggest  fetal  remains.  The  inner  surface  is  smooth 
and  presents  numerous  small  openings  which  represent  the  mouths  of 
glands.    The  membrane  is  1  to  3  mm.  thick. 

Microscopic  Examination. — In  general  the  membrane  may  be  said 
to  resemble  exudative  interstitial  endometritis.     The  surface  epithe- 


142     DIAGNOSIS  OF  EXPELLED  MEMBRANES  FROM  THE  UTERUS 

lium  may  be  intact  or  partially  or  wholly  lost.  The  glands  are 
irregularly  compressed  and  widely  separated.  A  rather  characteristic 
feature  is  the  zigzag  course  of  the  glands.  The  stroma  is  more  or  less 
crowded  with  small  round  cells.  In  the  lower  strata  are  frequently 
seen  large  connective-tissue  cells  which  closely  resemble  decidual 
cells.  The  presence  of  these  cells  sometimes  makes  it  diflfjcult  and  at 
times  impossible  to  distinguish  the  membrane  from  the  decidua  of 
pregnancy.  C.  Ruge  called  attention  to  the  fact  that  decidual  cells 
are  not  evidences  of  pregnancy ;  that  these  cells  are  found  in  occasional 
forms  of  endometritis. 

In  exfoliative  endometritis  these  connective-tissue  cells  are  less 
uniformly  enlarged  than  in  the  decidua  of  pregnancy,  and  upon  this 
fact  the  diagnosis  must  largely  be  based. 

The  Diagnosis  of  Expelled  Membranes 


Clinical 
features. 


Macro- 
scopic 
findings. 


Micro- 
scopic 
findings. 


Decidua  of  intra-uterine 
pregnancy. 


Symptoms  and  signs  of  preg- 
nancy; hemorrhage  and  pain 
accompanying  the  discharged 
membrane;  no  extra-uterine 
pelvic  tumor. 


Thiclj  shreds  with  shaggy  sur- 
face, or  smooth,  glistening 
membrane. 


Surface 
epithelium. 


Glands. 


Stroma. 


Vessels. 


Fetal 
tissue. 


Seldom  pres- 
ent. 


Compressed 
above,  widely 

dilated  and 
very  irregular 
below;  epithe- 
lium flattened. 

Typical  de- 
cidual cells. 


Very  widely 
dilated;  walls 

composed  of 
endothelium; 

no  muscula- 
ture. 

Chorionic 
villi!  amnion. 


Decidua  of  extra-uterine 
pregnancy. 


Symptoms  and  signs  of 
pregnancy;  often  irregu- 
lar hemorrhage  and  pain 
accompanying  the  dis- 
charged membrane;  ex- 
tra-uterine pelvic  tumor. 

Rough  fibrous  membrane; 
no  villous  structures;  ir- 
regularities on  inner  sur- 
face. 


Flattened;  may  be  want- 
ing. 


Changes  similar  to  intra- 
uterine   pregnancy, 
though  less  marked. 


Decidual  cells  not  so 
large;  more  intercellular 
substance. 


Less   widened   blood 
spaces. 


Absent. 


Decidua  of  menstruation. 


No    evidence    of    pregnancy; 
no  extra-uterine  pelvic  tumor. 


Unorganized. 

Fibrinous 
structure, 
external  sur- 
face smooth, 
internal  sur- 
face rough. 


Absent. 


Absent. 


Fibrinous 
network. 


Absent. 


Absent. 


Oroanized. 

Triangular 

cast  of  uterus, 

or  bits  of 

membrane; 

surface 
smooth  with 

sieve-like 
depressions. 

Cylindrical, 

rarely 

flattened  or 

lost. 

Zigzag  in 
their  course; 
epithelium 
cylindrical. 


Round-cell 
infiltration; 
protoplasm 
of  cells  in- 
creased. 

As  found  in 
endometritis. 


Decidual  cells  are  hypertwphied  connective-tissue  cells.  There  are 
causes  of  hypertrophy  of  these  cells  other  than  pregnancy,  and  hence  it  is 
that  decidual  cells  are  not  jJathognomonic  of  pregnancy.  The  only  posi- 
tive evidence  of  pregnancy  in  discharged  membranes  is  the  presence  of 
chorionic  villi. 


CHAPTER    IX 
ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY^ 

Etiology  Differential  Diagnosis 

Recurrent   and    Multiple  Ectopic   Treatment 

Pregnancy  Unruptured  Tubal  Pregnancy 

Combined  Uterine  and  Tubal  At  Time  of  Rupture 

Bilateral  Tubal  Late  after  Rupture 

Classification  j         Intraligamentary  Extra-uterine 

Ampullar  '  Pregnancj^ 

Interstitial  Interstitial  Pregnane}^ 

Infundibular  Advanced   Extra-uterine   Preg- 

Ovarian  !  nancy 

Causes  of  Ending  of  Gestation  I         Combined  Extra-uterine  and  Iiitra- 


Retrogressive    Changes    in    Dead 

Fetus 
Anatomical  Changes  in  Tube 
Clinical  Diagnosis 

Subjective  Signs 

Objective  Signs 


uterine  Pregnancy 

Ovarian  Pregnancy 

Pregnane}^  in  Rudimentary  Horn 
of  Uterus 
Mortality  of  Extra-uterine  Preg- 
nancy 


Etiology. — Predisposing  Causes. — 1.  INIechanieal  interference  with  the 
passage  of  the  o\'um  through  the  tube  from — 

(a)  Tumors  in  and  about  the  tube — i.  e.,  mucous  polyps,  ovarian 
and  parovarian  cysts. 

(b)  Persistence  of  the  fetal  type — small  himen  and  convoluted  course 
of  the  tube. 

(c)  Peritoneal  bands  constricting  the  tube  and  drawing  it  out  of 
position. 

(rf)  Congenital  anomalies  in  development,  namely,  diverticuli  and 
rudimentary  fimbriae. 

(e)  Malpositions  of  the  tube,  either  congenital  or  acquired. 

2.  Loss  of  cilia  and  epithelium  through  inflammation. 

Gonorrhea  has  been  mentioned  by  Gottschalk,  Braun-Fernwald,  and 
Bandler  as  a  frequent  forerunner  of  tubal  pregnancy.  Tuberculous 
and  puerperal  infections  of  the  tube  play  a  less  important  but  by  no 
means  insignificant  role.  Erich  Opitz  detected  signs  of  inflammation 
in  all  of  his  2.3  cases. 

Essential  Cause. — While  the  conditions  above  enumerated  are  fre- 
quently present,  it  is  a  matter  of  common  observation  that  tubal 
pregnancy  may  occur  in  an  apparently  normal  tube. 

Webster  affirms  that  in  ectopic  pregnancy  there  is  a  genetic  reaction 

1  The  author  acknowledges  his  indebtedness  to  J.  Clarence  Webster,  from  whose 
monograph  on  Ectopic  Pregnane}'  much  of  the  material  in  this  chapter  on  the 
classification  and  diagnosis  has  been  taken. 


144 


ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 


in  the  tube  which  is  essential  to  the  implantation  and  development 
of  the  ovum  in  the  tube,  as  truly  as  a  similar  genetic  reaction  in  the 
uterus  is  essential  to  uterine  gestation.  This  genetic  reaction  consists 
in  the  formation  of  decidual  tissue.  It  is  claimed  by  Webster  that  a 
decidua,  however  limited,  is  always  found  in  the  pregnant  tube.  With- 
out a  decidua  the  ovum  would  find  no  abiding  place  in  the  tube,  even 
in  the  presence  of  predisposing  causes.  In  the  event  of  a  decidual 
formation  in  the  tube  the  predisposing  causes  serve  to  obstruct 
the  passage  of  the  ovum,  and  make  possible  the  implantation  of  the 
ovum  in  the  tube  rather  than  in  the  uterus. 


Ectopic  gestation  in  a  blind  accessory  fimbriated  extremity  of  the  right  tube.     (Jewett.) 


Ectopic  pregnancy  may  occur  at  any  time  during  the  period  of 
sexual  maturity,  but  its  greatest  frequency  is  between  the  ages  of 
thirty  and  forty.  It  is  stated  that  a  long  period  of  sterility  predisposes 
to  ectopic  pregnancy,  probably  because  of  the  existence  of  one  or 
more  of  the  predisposing  causes.  Tubal  gestation  occurs  five  times  as 
frequently  in  multiparse  as  in  primiparse — a  fact  which  may  again  be 
explained  on  the  ground  of  the  development  of  the  predisposing 
causes. 

Recurrent  and  Multiple  Ectopic  Pregnancy.  —  Recurrence  of  Tubal 
Pregnancy  in  the  Same  Tube  or  in  the  Opposite  Tube. — Occasionally 
there  are  reports  of  cases  in  which  a  second,  third,  or  even  fourth  preg- 
nancy has  occurred  in  the  same  tube  or  has  occurred  alternately  in 
both  tubes.  In  a  case  of  Grandin  the  second  pregnancy  was  recognized 
only  two  months  subsequent  to  the  first  tubal  pregnancy.  H.  C.  Hindler 
reported  a  case  recurring  in  the  stump  of  a  tube  that  had  been  pre- 
viously amputated  for  tubal  pregnancy. 


MULTIPLE  ECTOPIC  PREGNANCIES  145 

Multiple  Ectopic  Pregnancies. — There  may  be  twin  pregnancies  in 
one  tube,  in  both  tubes,  or  in  the  uterus  and  one  tube.  Again,  the 
uterus  and  both  tubes  may  each  contain  an  ovum. 


Fig.  66 


Tubal  abortion  on  right  side;  hematosalpinx  on  left  side,  the  result  of  a  tubal  pregnancy  one  year 
previous.     The  uterus  is  reconstructed. 

Dr.  Richard  R.  Smith  reported  170  cases  of  ectopic  pregnancy  which 
recurred  one  or  more  times;  four  of  these  cases  were  his  own.  The 
author  has  had  but  one  such  case.  The  fact  that  the  opposite  tube  may 
subsequently  become  pregnant  after  the  removal  of  a  pregnant  tube  is 
no  argument  in  favor  of  removing  a  healthy  tube  in  the  presence  of 
a  pregnancy  in  the  opposite  tube.  Smith  finds  less  than  4  per  cent, 
of  recurrences  in  the  opposite  tube.  Hindler  reported  a  case  recurring 
in  the  stump  of  a  tube  that  was  previously  removed  for  tubal  pregnancy. 

Combined  Uterine  and  Tubal  Pregnancy. — Hanna  found  69  cases  of 
tubal  pregnancy  associated  with  uterine  pregnancy.  Vilkin  reported 
68  cases  in  literature,  in  20  of  which  both  fetuses  approached  maturity. 
Simpson  reviewed  the  history  of  113  cases,  and  added  one  of  his  own. 
He  gives  the  following  classification: 

Class  1.  The  woman  becomes  pregnant  while  carrying  the  dead 
products  of  an  ectopic  gestation. 

Class  2.  The  ectopic  and  uterine  gestation  are  both  living  at  the 
same  time. 

(o)  Ectopic  gestation  precedes  the  uterine. 

(6)  Ectopic  gestation  follows  the  uterine. 

(c)  Ectopic  and  uterine  gestation  occur  coincidently. 

Bilateral  Tubal  Pregnancy. — A  review  of  the  literature  on  ectopic 
gestation  discloses  the  records  of  a  large  number  of  cases  in  which 
pregnancy  has  occurred  in  the  same  tube  or  in  the  opposite  tube. 
Almost  as  frequent  are  the  references  to  combined  tubal  pregnancy 
and  uterine  pregnancy.  Several  cases  of  twin  pregnancy  in  a  single 
tube  and  one  of  triplets  are  recorded.  The  author  has  been  able  to  find 
10 


146 


ECTOPIC  OR  EXTRA-UTERINE  PREGXANCY 


records  of  28  cases  of  bilateral  tubal  pregnancy,  but  in  the  majority 
of  these  cases  the  proofs  are  by  no  means  conclusive. 

Bland  Sutton  quotes  Parry  as  follows:  "Twin  conceptions  are 
much  more  frequent  in  extra-uterine  than  they  are  in  normal  gestation 
(four  to  one).  It  is  a  striking  fact,  however,  that  both  children  are 
rarely  developed  in  the  same  locality.  In  a  large  majority  of  these 
tubal  conceptions  one  ovum  finds  its  way  into  the  interior  of  the  uterus, 
while  the  other  is  arrested  at  some  point  in  its  descent.  This  fact  has 
led  Professor  Barnes  to  believe  that  twin  conception  is  one  cause  of 
extra-uterine  pregnancy."  Bland  Sutton  fails  to  concur  in  the  views 
of  Parry. 

In  reviewing  the  reports  of  cases  of  bilateral  tubal  pregnancy,  it  is 
evident  that  in  some  the  products  of  conception  were  of  simultaneous 
development;  in  others  it  is  equally  clear  that  the  development  of  the 
two  ova  was  not  of  the  same  period,  and  in  the  majority  of  cases  there 
was  no  conclusive  evidence  on  this  point. 


Fig.  67 


Bilateral  tubal  pregnancy  (coincident  development).     Right  tubal  abortion,  left  tubal  rupture. 

(Flndlej'.) 

Of  the  28  cases  reported  as  examples  of  bilateral  tubal  pregnancy, 
but  8  are  unquestioned.  Of  the  20  cases  of  doubtful  identity,  the 
clinical  diagnosis  was  not  supported  by  the  macroscopic  and  microscopic 
findings  of  fetal  structures  in  the  two  tubes. 

In  the  case  (Fig.  67)  which  was  reported  by  the  author^  there  was 
the  escape  of  the  ovum  and  blood  through  the  abdominal  end  of  the 
left  tube  and  of  its  twin,  through  a  rent  in  the  ampulla  of  the  right  tube. 

Placental  tissue,  decidua,  and  chorionic  villi  were  found  in  both 
tubes,  but  neither  fetus  was  discernible.  Both  ovaries  were  cystic 
and  were  bound  by  adhesions  to  neighboring  structures.  In  the  right 
ovary  was  a  fresh  corpus  luteum. 

Classification. — In  nearly  three-fourths  of  the  cases  the  ovum  develops 
in  the  ampullary  portion  of  the  tube  and  with  about  equal  frequency 
in  the  interstitial  and  fimbriated  portions. 

1  Surgery,  Gynecology,  and  Obstetrics,  July,  1910. 


AMPULLAR  TUBAL  PREGNANCY 


147 


Ampullar  Tubal  Pregnancy. — -The  gestation  begins  in  the  ampullar 
end  of  the  tube.  Ampullar  tubal  pregnancy  may  persist  as  such,  or 
the  gestation  sac  may  rupture  from  the  tube. 

Persistent. — In  rare  instances  the  gestation  in  the  ampulla  may 
go  to  full  term.  The  gestation  sac  is  pedunculated,  movable,  incar- 
cerated, or  fixed  by  adhesions.  When  confined  to  the  pelvis  the  uterus 
and  ovary  are  crowded  to  the  opposite  side;  when  large  and  lying  in 
the  abdominal  cavity  the  uterus  may  not  be  displaced.  As  a  rule, 
the  gestation  sac  lies  at  the  side  of  or  behind  the  uterus,  rarely  between 
the  bladder  and  uterus.  Adhesions  may  firmly  bind  the  tube,  uterus, 
and  ovary  together. 

Fig.  68 


Ectopic  pregnancj-  located  in  the  uterine  end  of  the  tube.  This  might  be  called  a  tubo-interstitial 
pregnancy,  inasmuch  as  the  uterus  formed  a  part  of  the  gestation  sac.  The  pregnancy  had  advanced 
about  eight  weeks.     Rupture  had  not  occurred.     (Specimen  reconstructed.) 


Rupture. — Rupture  may  occur  early.  The  most  likely  exit  is 
between  the  layers  of  the  broad  ligament,  though  not  infrequently  it 
ruptures  into  the  free  peritoneal  cavity. 

Intraligamentary  Gestation. — The  ovum  escapes  through  the  lower 
segment  of  the  tube  between  the  layers  of  the  broad  ligament.  Here 
the  ovum  may  perish  or  go  on  to  full  development.  Rupture  usually 
takes  place  not  later  than  the  fourteenth  week.  The  escape  of  the 
fetus  and  blood  may  be  gradual  or  abrupt.  The  process  may  be  so 
gradual  that  no  general  disturbance  will  be  caused,  and,  on  the  other 
hand,  the  fetus  and  blood  may  be  discharged  in  such  a  manner  as  to 
occasion  profound  shock.  As  the  gestation  sac  enlarges  the  layers  of 
the  broad  ligament  are  separated,  the  pelvic  viscera  are  pushed  to  one 
side,  the  peritoneum  is  stripped  from  the  bladder,  uterus,  rectum,  and 
pelvic  wall.  Later,  as  the  gestation  sac  increases  in  size,  it  burrows 
beneath  the  parietal  and  visceral  peritoneum,  crowding  the  viscera 
forward  and  to  the  opposite  side. 

The  placenta  may  remain  attached  to  the  tube  or  escape  with  the 
fetus  between  the  lavers  of  the  broad  ligament  and  become  attached 


148 


ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 


to  any  of  the  raw  surfaces.  The  tube  may  be  stretched  out  over  the 
gestation  sac  as  a  mere  ridge.  Rupture  into  the  peritoneal  cavity  may 
take  place  at  any  time  after  the  escape  of  the  ovum  and  blood  between 
the  layers  of  the  broad  ligament.  The  danger  to  life  in  such  an  event 
is  imminent,  and  immediate  surgical  interference  is  imperative. 


Fig.  69 


Schematic  drawing  showing  locations  of  ectopic  pregnancy,     a,  interstitial;  6,  ampullary; 
c,  infundibular;  d,  tuboovarian;  e,  ovarian. 

Fig.  70 


Left  Fallopian  tube  with  ectopic  gestation  in  diverticulum,     a,  a,  gestation  sac  coinmunicating 
with  diverticulum.     (Jewett.) 


Tuboperitoneal  Gestation. — In  tuboperitoneal  gestation  the  placenta 
remains  in  the  tube  and  the  fetus  escapes  into  the  peritoneal  cavity. 
The  probability  of  such  a  condition  was  long  held  impossible.  The 
first  authentic  case  reported  was  that  of  Croom.  Webster  made 
sectional,  dissectional,  and  microscopic  studies  of  the  case,  and  proved 


PLATE    VI 11 


Secondary  Abdominal  Pregnancy  at  Eight  Months, 
Primarily  Tubal. 

The  primary  attachment  of  the  placenta  is  plainly  discernible  at  the 
original  tubal  site.  After  rupture  the  placenta  grew  and  became  attached  to 
a  large  surface  on  the  anterior  abdominal  wall.  The  child  was  delivered 
through  a  retrouterine  vaginal  incision.      (Jewett.) 


AMPULLAR   TUBAL   PREGXAXCY  U9 

the  existence  of  tuboperitoneal  gestation  beyond  dispute.  AYebster  holds 
that  it  is  as  yet  improved  that  a  fetus  can  escape  into  the  peritoneal 
cavity  free  of  its  investing  membranes  and  then  develop  to  full  term; 
he  doubts  the  probability  of  such  an  occurrence.  Furthermore,  it  is 
as  yet  unproved  that  the  early  complete  ovum  can  escape  into  the 
peritoneal  cavity  and  then  go  on  to  develop.  As  stated  by  Webster, 
it  is  inconceivable  that  a  villous-covered  o\'um  can  escape  into  the 
peritoneal  cavity  and  there  await  the  development  of  intervillous 
blood  spaces. 

Gestation  may  terminate  by  rupture  of  the  tube  and  escape  of  blood 
into  the  free  peritoneal  cavity.  The  amount  of  blood  lost  may  be 
insignificant  and  occasion  no  constitutional  effects;  while,  again,  the 
blood  may  instantly  escape  in  such  large  amounts  as  to  jeopardize  the 
life  of  the  mother  and  fetus  unless  surgical  intervention  is  prompt. 
The  consequences  to  the  mother  are,  therefore,  dependent  upon  the 
extent  of  the  tear,  the  rapidity  with  which  the  blood  is  allowed  to  escape, 


Primarj-  intraperitoneal  rupture;  fifth  week.     Tube  completely  ruptured,     a,  o^-um  still  slightlj- 
adherent  to  its  original  site.     (Jewett.) 

and,  finally,  upon  timely  surgical  interference.  The  fetus  may  plug 
the  opening  and  prevent  the  escape  of  much  blood,  or  the  blood  may 
escape  at  intervals  and  eventually  assume  large  proportions  without 
seriously  depressing  the  patient.     (See  Plate  ATIL) 

Interrupted  hemorrhage  may  also  be  due  to  contraction  and  retraction 
of  the  tube  and  bloodvessels.  Though  the  quantity  of  blood  lost  in 
interrupted  hemorrhages  may  be  equally  as  great  as  in  the  immediate 
escape  of  blood,  the  effect  upon  the  mother  is  far  less  serious.  The 
later  in  pregnancy  the  rupture  occurs  the  more  serious  the  consequences, 
because  of  the  unusual  size  of  the  rent,  the  failure  of  the  muscular  vrall 
to  retract,  the  presence  of  large  blood  sinuses,  and  the  failure  on  the 
part  of  the  fetus  to  be  absorbed. 

Prior  to  the  end  of  the  second  month,  if  rupture  takes  place,  the 
hemorrhage  will  usually  not  be  great,  and  the  fetus  will  almost  cer- 
tainly be  absorbed.  Paipture  has  been  known  as  early  as  the  second 
week.     The  time  of  greatest  frequency  for  rupture  to  occur  is  from 


150  ECTOPIC  OR  EXTRA-UTERIXE  PREGNANCY 

the  sixth  to  the  fourteenth  week.  The  greatest  number  rupture  in  the 
second  month. 

The  escaped  blood  accumulates  in  the  most  dependent  portion  of  the 
pelvic  cavity.  There  it  is  rapidly  coagulated,  and  is  later  absorbed, 
suppurates,  or  is  organized. 

Fritsch  says  there  is  no  case  of  pelvic  hematocele  in  which  ectopic 
pregnancy  can  be  positively  ruled  out;  while,  on  the  other  hand,  such 
authorities  as  Kober  and  Freund  have  reported  cases.  It  is  unusual 
for  acute  peritonitis  to  follow  the  development  of  a  hematocele,  though 
it  is  the  rule  for  peritoneal  adhesions  to  form  about  the  mass  of  escaped 
blood. 


Tubal  abortion.  A  large  intraperitoneal  hemorrhage  occurred  in  the  second  month  of  pregnancy. 
The  tube  is  dark  red  and  larger  than  a  man's  thumb.  From  the  abdominal  end  of  the  tube  a  blood 
coagulum  is  seen  to  escape. 

Interstitial  Tubal  Pregnancy. — In  this  form  the  portion  of  the  tube 
lying  within  the  uterine  wall  encloses  the  gestation  sac.  This  is  an 
unusual  location.  There  may  be  tubo-uterine  pregnane^',  in  which  the 
ovum  lies  partly  within  the  interstitial  portion  of  the  tube,  and  partly 
within  the  uterine  cavity.  Again,  the  ovum  may  first  develop  within 
the  interstitial  portion  of  the  tube,  and  later  be  expelled  into  the  cavity 
of  the  uterus  ("tubal  abortion").  The  gestation  sac  forms  a  part  of 
the  uterine  tumor,  and  lies  within  the  attachment  of  the  round  ligament 
— all  other  forms  of  tubal  pregnancy  lie  external  to  the  round  ligament. 
Interstitial  pregnancy  may  go  on  to  full  term;  the  fetus  may  die  at 
any  period  of  its  development,  or,  finally,  rupture  of  the  tube  may 
permit  the  ovum  to  escape  into  the  uterine  cavity  between  the  layers 
of  the  broad  ligament  or  directly  into  the  peritoneal  cavity.  In  any 
event,  the  resulting  hemorrhage  may  be  fatal. 

Infundibular  Tubal  Pregnancy. — The  ovum  is  found  in  the  infundibu- 
lum.  This  is  an  unusual  condition.  The  behavior  is  similar  to  that 
of  ampullar  pregnancy.  The  tube  is  likely  to  adhere  to  surrounding 
structures,  and  by  adhering  to  the  ovary  a  tuboovarian  pregnancy 
becomes  possible. 


OVARIAN  PREGNANCY 


151 


Ovarian  Pregnancy. — Contrary  to  earlier  conceived  notions  primary 
ovarian  pregnancy  does  exist.  Two  cases  of  ovarian  pregnancy  are 
reported  by  Webster.    About  20  cases  are  now  on  record. 


Fig.  73 


Interstitial  pregnancy.     (Sutton.) 
Fig.  74 


Amnion 


Partially 
separated 
placenta. 


Ulerine      [i 
cavitj 


-ervix 


Interstitial  pregnancy.     (Bumm.) 


152 


ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 


Williams  collected  13  positive  and  22  probable  cases  from  the 
literature.  Eleven  of  this  number  progressed  to  full  term,  which 
suggests  that  the  ovary  is  more  capable  of  accommodating  the  grow- 
ing ovum  than  is  the  tube.  No  definite  decidua  was  found  in  any 
of  the  cases.  The  ovum  advanced  to  full  term  or  died  in  situ  in  a 
minority  of  the  cases.  Rupture  with  escape  of  blood  and  fetus  was 
the  rule. 

Causes  of  Ending  of  Gestation. — The  Formation  of  a  Hematoma. — 
The  accumulated  blood  destroys  the  life  of  the  fetus.  Rupture  of  the 
tube  has  been  known  to  occur  after  the  death  of  the  fetus  (Braun- 
Fernwald).  The  growth  of  the  placenta  subsequent  to  the  death  of 
the  fetus  is  the  probable  cause  of  rupture.  The  lower  the  attach- 
ment of  the  placenta  the  greater  the  hemorrhage,  and  hence  the 
greater  the  likelihood  that  the  life  of  the  fetus  will  be  destroyed. 
The  escaped  blood,  if  large  in  amount,  may  undermine  the  perito- 
neum, and  sometimes  encircles  the  uterus  and  rectum  and  displaces 
the  uterus.  Coagulation  of  the  blood  is  rapid,  and  eventually  com- 
plete absorption  of  the  clots  or  the  organization  of  the  clots  into 
adhesions  follows,  unless,  perchance,  the  escaped  blood  suppurates 
and  forms  a  pelvic  abscess. 


Fig.  75 


Ampullar  tubal  pregnancy.     Fetus  surrounded  by  a  blood  coagulum. 

Suppuration. — This  event  is  usually  late  in  its  occurrence.  It  is 
unusual  for  an  acute  abscess  to  follow  a  hematoma  of  the  pelvis.  The 
more  intimate  the  relation  to  the  bowel  the  greater  the  liability  of 
the  escaped  blood  to  suppurate.  If  the  abscess  is  not  opened  by 
surgical  means  it  may  become  absorbed,  but  will  more  probably 
find  its  way  to  a  hollow  viscus  or  externally  through  the  vagina  or 


PLATE    rX 

Fig,    1 


Fig.    2 


f 


Ovarian  Pregnancy.      CW'ebster.j 


TUBAL  ABORTION 


153 


abdominal  wall.  Parry  reports  a  case  in  which  rupture  occurred 
thirty-two  years  after  the  formation  of  an  abscess.  Twelve  cases  are 
recorded  in  which  the  fetus  was  discharged  through  the  bowel. 

Tubal  Abortion. — By  tubal  abortion  is  meant  the  escape  of  the  ovum 
through  the  fimbriated  end  of  the  tube  into  the  peritoneal  cavity. 
This  implies  that  the  tube  must  be  patent  at  its  fimbriated  end.  Accord- 
ing to  Dobberts,  tubal  abortion  is  three  to  four  times  as  frequent  as 
rupture  of  the  tube.    All  authorities  agree  that  it  is  much  more  frequent 


Fig.  76 


Intraligamentary  rupture  of  a  tubal  pregnancy.     Rupture  at  the  isthmus,  with  escape  of  the  fetus. 

(Jewett.) 


than  rupture  of  the  tube.  The  contractions  of  the  tube  expel  the 
ovum,  forcing  it  in  the  direction  of  least  resistance.  The  nearer  the 
attachment  of  the  ovum  to  the  fimbriated  end  of  the  tube  the  greater 
the  likelihood  of  abortion.  Hemorrhage  is  rarely  considerable.  The 
author  removed  two  gallons  of  blood  from  the  peritoneal  cavity  as 
the  result  of  tubal  abortion.  All  that  has  been  said  of  tubo-abdominal 
gestation  in  reference  to  the  fate  of  the  mother  and  ovum  applies  to 
tubal  abortion,  though  with  less  force.     The  hemorrhage  is  rarely  so 


154  ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 

great  and  the  fetus  is  usually  absorbed.     Hence  the  mother  may  and 
indeed  often  does  suffer  but  little  (Fig.  72). 

Formation  of  a  Mole. — The  fetus  dies  and  is  preserved  in  its  entirety, 
forming  a  fleshy  mole.  The  death  of  the  ovum  is  caused  by  an  escape 
of  blood  into  the  fetal  membranes.  At  first  the  mass  appears  like  a 
fresh,  firm,  blood-clot.  Later  it  organizes  and  becomes  paler  as  the 
blood  absorbs. 

The  Formation  of  an  Adipocere,  a  Lithopedion  or  Mummy.  —  When 
the  fetus  is  far  advanced  in  its  development  it  is  liable  to  one  of  these 
formations. 

Retrogressive  Changes  in  a  Dead  Fetus. — Mummification. — Mum- 
mification is  a  process  of  desiccation  in  which  the  water  is  extracted 
from  the  fetus.  In  addition  a  deposit  of  earthy  salts  is  often  super- 
imposed. 

Calcification. — In  calcification  the  fetal  membranes  and  placenta  and 
rarely  the  superficial  parts  of  the  fetus  are  permeated  and  incrusted 
with  lime  salts.  A  dense  incrustation  is  seldom  formed.  It  is  not  un- 
common for  an  adhesive  peritonitis  to  develop  about  the  lithopedion. 
The  petrified  ovum  may  remain  in  the  tube,  in  the  peritoneal  cavity, 
or  between  the  layers  of  the  broad  ligament  for  years  without  creating 
serious  disturbance.  Well-formed  children  may  be  born  while  the 
parent  still  carries  a  lithopedion. 

Adipocere  Formation. — In  adipocere  formation  the  ovum  is  converted 
into  a  soap-like  mass.  Calcareous  deposits  may  be  found  in  the 
fetal  structure. 

Gangrene  of  the  Fetus. — Gangrene  of  the  fetus  may  result,  and  if 
surgical  interference  is  not  instituted,  death  from  septic  infection  and 
peritonitis  will  probably  follow. 

Anatomical  Changes  in  the  Tube.— Mucous  Membrane.— In  the 
tubal  mucosa  decidual  changes  are  always  to  be  found  (Webster). 
This  view  is  not  universally  accepted.  Webster  has  never  failed  to 
demonstrate  a  decidua  in  the  tube,  but  finds  great  variation  in  the 
location  and  extent  of  the  development.  The  early  specimens  show 
this  so-called  genetic  reaction  more  clearly  than  do  the  advanced  cases. 
The  decidua  may  be  confined  to  a  narrow  ring  about  the  tube.  It  is, 
therefore,  not  strange  that  conflicting  statements  are  made  concerning 
the  presence  of  a  decidua  in  the  tube,  for,  it  is  often  necessary  to 
make  sections  from  various  portions  of  the  tube. 

Asin  uterine  pregnancy,  so  in  the  tube,  a  decidua  vera,  reflexa,  and 
serotina  are  usually  found.  The  decidua  vera  is  composed  of -a  spongy 
and  compact  layer,  as  in  uterine  pregnancy.  In  the  compacta  the 
decidual  cells  are  closely  packed  together,  while  in  the  spongy  layer 
they  are  separated  by  gland-like  spaces  formed  by  mucous  folds.  In 
later  months  the  distinction  between  the  compact  and  spongy  layers 
is  lost.  In  the  earlier  stages  the  surface  epithelium  remains  intact,  but 
as  time  goes  on  the  cilia  are  lost,  the  surface  cells  become  flattened, 
and,  finally,  wholly  disappear.  As  in  the  endometrium,  the  decidual 
cells  are  derived  from  the  connective  tissue  of  the  mucosa.    They  are 


PLATE    X 


Fig.    1 


Hematoma  of  the  Left  Broad  Ligament  Lying  Close  to 

the  Uterus. 


Fig.    2 


Hematoma  of  the  Left  Broad  Ligament  and  Extending  in 
Front  of  the  Cervix  to  tlie  Right  Side  of  the  Uterus. 


PLATE    XI 


Hematoma  of  both  Broad  Ligaments  Extending  in  Front 

of  the  Uterus. 


Fig.    2 


Hemiatoma  of  both  Broad  Ligaments  Connected  Behind 

the  Uterus. 


THE  CLIXICAL  DIAGXOSIS  155 

essentially  greatly  enlarged  connective-tissue  cells,  and  show  great 
variation  in  size  and  form.  In  far-advanced  cases  these  cells  become 
elongated  into  a  fibrous  structure  and  lose  their  decidual  character. 

The  decidua  serotina,  that  portion  of  the  decidua  kno-uTi  as  the 
placental  site,  is  relatively  larger  than  the  serotina  of  the  pregnant 
uterus. 

The  decidua  reflexa  may  or  may  not  be  present.  Some  authorities 
disclaim  its  existence.  According  to  Webster,  the  ttibe  lumen  may 
be  so  small  that  the  ovum,  pressing  upon  the  wall  of  the  ttibe,  makes 
the  formation  of  a  decidua  reflexa  impossible.  On  the  other  hand, 
the  tube  lumen  may  be  exceptionally  large,  in  which  case  a  complete 
reflexa  may  be  formed.  As  the  ovum  develops  the  reflexa  becomes 
thin  and  early  disappears. 

Beyond  the  attachment  of  the  OA'iim  the  tubal  mucosa  may  not 
suffer  change;  occasionally,  however,  decidual  changes  are  recognized 
throughout  the  entire  mucosa  of  the  tube.  As  the  ovum  enlarges 
and  fills  the  tube,  the  surface  epithelium  is  compressed  and  wholly 
disappears;  so,  also,  with  the  decidua. 

The. muscular  wall  of  the  tube  varies  in  thickness  in  different  sections 
and  in  the  various  stages  of  pregnancy.  In  the  early  months  the 
musculature  thickens  through  h^'pertrophy.  In  the  later  months 
pressiu^e  and  stretching  of  the  musculature  may  cause  aU  traces  of 
muscle  fibers  to  disappear. 

The  peritoneal  covering  of  the  tube  is  stretched  by  the  growing 
o\'um  and  inflammatory  adhesions  may  form  about  the  tube. 

Regarding  the  fetal  membranes,  there  is  little  that  differs  from  the 
membranes  of  normal  uterine  gestation. 

The  Clinical  Diagnosis. — Huggins  believes  that  a  diagnosis  should 
be  made  in  SO  per  cent,  of  unrtiptiu-ed  cases  provided  the  physician  is 
called  in  time.  To  achieve  this  it  is  necessary  that  the  p^e^dous  his- 
tory, as  well  as  the  present  complaints  of  the  patient,  be  very  care- 
fully considered. 

Consideration  of  the  History. — The  examiner  should  go  back  years 
into  the  history  for  the  discovery  of  symptoms  suggestive  of  tubal 
infection.  These  s^Tnptoms  may  ha^'e  been  pronounced  at  one  time 
or  they  may  have  been  mild  from  the  beginning.  A  history  of  a  latent 
gonorrhea  in  the  husband  may  be  the  flrst  suggestion  of  a  possible 
ttibal  involvement  in  the  wife.  A  period  of  sterility  is  presumptive 
evidence  of  tubal  involvement.  When  the  patient  has  had  a  perfectly 
normal  menstrual  history  and  at  examination  presents  definite  irregu- 
larities, such  as  delayed  onset  of  the  menstrual  periods  or  excessive 
and  possibly  painful  periods,  a  suspicion  of  ectopic  pregnancy  is 
awakened.  Again,  when  the  menstrual  period  has  been  missed  for  from 
one  to  three  weeks  and  then  begins  with  pain  in  the  hj-pogastriimi, 
the  possible  presence  of  ectopic  pregnancy  should  be  considered. 

The  clinical  diagnosis  of  ectopic  pregnancy  is  made,  first,  by  estab- 
lishing the  fact  of  pregnancy,  and,  second,  by  locating  the  gestation 
sac.    The   subjective  signs   are  of  value  in  establishing  the  fact   of 


150)  ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 

pregnancy,  but  the  location  of  the  gestation  sac  can  only  be  determined 
by  a  physical  examination. 

Subjective  Signs. — The  subjective  signs  may  not  differ  materially 
from  those  of  uterine  pregnancy  of  a  similar  age.  In  the  early  weeks 
of  an  ectopic  gestation  the  patient  is  seldom  aware  of  any  unusual 
complications,  while  in  the  later  months  the  symptoms  rarely  conform 
to  those  of  normal  pregnancy,  and  give  rise  to  feelings  of  apprehension 
on  the  part  of  the  patient.  Not  so  with  the  physical  signs;  these  are 
to  be  differentiated  from  the  normal  from  the  earliest  time. 

Cessation  of  Menstruation. — This  occurs  in  about  one-half  of  the 
cases.    The  hemorrhage,  when  present,  comes  from  the  endometrium. 

Morning  Sickness. — Morning  sickness  occurs  at  about  the  same  time 
and  to  about  the  same  extent  as  in  uterine  pregnancy. 

Nervous  Phenomena.- — Nervous  phenomena,  such  as  ringing  in  the 
ears  and  despondency,  are  likely  to  be  more  marked  than  in  normal 
uterine  gestation. 

Periodic  Colicky  Pains.- — Periodic  colicky  pains  are  unlike  anything 
that  should  occur  in  normal  uterine  pregnancy.  It  is  this  incident 
that  commonly  first  attracts  the  patient's  attention  to  her  condition. 
These  pains  are  said  to  be  due  to  the  contractions  of  the  uterus  and 
pregnant  tube.  In  character  they  are  intermittent  and  cramping,  and 
are  located  in  the  region  of  the  uterus  and  affected  tube.  During 
these  pains  rupture  of  the  gestation  sac  may  occur. 

Objective  Signs. — The  objective  signs  differ  essentially  from  those  of 
uterine  gestation. 

Mammary  Glands. — The  mammary  glands  do  not  often  show  the 
marked  changes  accompanying  uterine  pregnancy.  The  areola  is 
poorly  marked  and  the  secretion  of  colostrum  is  scant. 

Discoloration  of  the  Vulva  and  Vagina,  Softening  of  the  Vaginal 
Portion  of  the  Cervix,  and  Comi^ressibility  of  the  Lower  Uterine  Segment. 
— These  may  all  be  present,  but  seldom  to  the  degree  found  in  uterine 
gestation. 

Active  Fetal  Movements. — Active  fetal  movements  may  be  recognized 
earlier  and  with  greater  ease  than  in  uterine  pregnancy,  provided  the 
fetus  lies  in  close  proximity  to  the  abdominal  wall.  Later  on  the 
movements  may  be  readily  seen  through  the  parietes. 

Intermittent  Uterine  Contraction. — Intermittent  uterine  contractions 
are  often  present,  though  not  to  the  degree  found  in  uterine  pregnancy. 

Direct  Palpation. — Direct  palpation  of  the  fetal  parts  may  be  very 
difficult  and  obscure,  or  very  easy,  depending  upon  the  relation-  of  the 
fetus  to  the  abdominal  wall. 

Auscultation. — (a)  Fetal  heart  tones  are  heard  with  varying  degrees 
of  distinctness,  depending  upon  the  development  of  the  fetus,  its 
relation  to  the  abdominal  wall  and  upon  the  thickness  of  the  latter. 
(6)  The  fetal  souffle  is  rarely  heard,  and  only  in  the  latter  half  of  preg- 
nancy, (c)  The  placental  souflfle  is  rarely  heard  after  the  third 
month,  and  only  on  the  side  occupied  by  the  gestation  sac. 


OBJECTIVE  SIGNS  157 

The  Rate  of  Growth,  Form,  Position,  and  Consistency  of  the  Uterus. — 
These  vary  considerably  from  that  of  uterine  gestation.  While  the 
uterus  almost  always  enlarges,  it  never  attains  a  greater  size  than  that 
of  a  four  months'  pregnant  uterus,  and  does  not  enlarge  regularly 
and  progressively  as  does  the  gravid  uterus.  The  nearer  the  gestation 
sac  is  to  the  uterus  the  larger  the  uterus  develops.  Cases  are  recorded 
in  which  the  uterus  did  not  develop,  but  these  are  exceedingly  rare. 

The  general  contour  of  the  uterus  differs  somewhat  from  that  of 
the  normal  pregnant  uterus.  It  retains  much  the  same  form  as  does 
the  non-pregnant  uterus.  The  transverse  diameter  is  proportionately 
less,  and  there  is  no  shortening  of  the  cervix  in  advanced  cases. 

The  uterus  seldom  lies  in  the  median  line,  but  is  usually  crowded 
to  one  side  by  the  gravid  tube. 

In  consistency  the  uterus  changes,  but  not  to  the  degree  found 
in  uterine  gestation. 

Discharge  of  the  Uterine  Decidua. — The  discharge  of  the  uterine 
decidua  is  an  event  peculiar  to  ectopic  pregnancy.  Part  or  all  of  the 
uterine  decidua  may  be  expelled  at  any  time  during  the  course  of  an 
ectopic  pregnancy.  As  a  rule,  the  decidua  is  expelled  piecemeal,  rarely 
in  its  entirety.  Much  blood  may  accompany  the  discharged  decidua 
and  completely  mask  the  accompanying  fragments.  When  ectopic 
pregnancy  is  suspected  the  escaped  blood  should  be  carefully  preserved 
by  the  nurse  for  the  inspection  of  the  physician. 

Histologically,  the  uterine  decidua  of  ectopic  pregnancy  does  not 
differ  essentially  from  that  of  uterine  gestation,  the  distinguishing 
feature  being  the  absence  of  fetal  structures. 

Spurious  Labor. — At  full  term  pains  not  unlike  those  of  labor  come 
on  and  constitute  what  is  known  as  spurious  labor.  These  pains  may 
occur  weeks  before  the  end  of  full  term,  and,  on  the  other  hand,  may 
altogether  fail  or  be  delayed  one  or  more  months  beyond  full  term. 
The  pains  commonly  continue  a  number  of  hours,  as  in  normal  labor, 
but  have  been  known  to  persist  for  a  week  and  longer.  They  vary  in 
intensity  and  location;  often  they  are  severe  and  located  in  the  side 
of  the  pelvis.  A  bloody  discharge  appears  shortly  after  the  onset  of 
the  pain,  and  with  it  there  is  usually  a  discharge  of  decidual  membrane. 
The  amount  of  blood  lost  may  be  alarming. 

Following  spurious  labor  the  fetus  always  dies,  the  liquor  amnii 
becomes  absorbed,  the  gestation  sac  contracts,  and  the  fetus  under- 
goes changes  previously  referred  to,  namely,  mummification,  litho- 
pedion,  gangrene,  or  adipocere  formations. 

Intraperitoneal  Hemorrhage. — An  intraperitoneal  hemorrhage  should 
be  suspected  when  a  woman  in  the  childbearing  age  experiences  a 
sudden  and  severe  abdominal  pain  with  the  appearance  of  extreme 
anemia  and  faintness.  As  the  pallor  increases  the  pulse  becomes 
increasingly  rapid  and  compressible  and  may  become  imperceptible, 
the  respirations  are  sighing,  restlessness  develops,  and  the  temper- 
ature becomes  subnormal.  The  abdomen  may  become  somewhat 
distended  and  tender,  with  more  or  less  rigidit}-.     Death  may  follow 


158  ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 

within  a  few  hours  or  the  bleeding  may  be  checked  spontaneously  and 
the  patient  recover. 

Bimanuol  Examination. — An  anesthetic  will  be  found  of  immense 
advantage  in  making  a  bimanual  examination,  but  should  not  be  given 
if  the  patient  is  greatly  depressed.  Great  variations  are  observed  in 
the  local  findings  of  ectopic  pregnancy.  Vessels  may  be  felt  to  pulsate 
in  the  vaginal  vault,  particularly  on  the  side  of  the  gestation  sac.  The 
vagina  may  be  displaced  and  misshaped  by  the  gestation  sac  and 
accumulated  blood  above.  The  vaginal  walls  may  bulge  at  the  sides 
and  behind  the  uterus,  and  the  vagina  may  be  pushed  far  to  one  side. 

The  uterus  is  almost  invariably  displaced  by  the  tumor  mass.  The 
most  common  displacement  is  forward  and  upward,  because  of  the 
frequency  with  which  the  blood  collects  in  the  pouch  of  Douglas, 
The  uterus  is  elongated,  but  is  never  so  broad  as  in  uterine  gestation 
of  a  similar  period  of  development.  Its  consistency  is  firmer  than 
in  uterine  pregnancy,  the  lower  uterine  segment  is  not  well-marked, 
and  the  cervix  is  not  shortened. 

The  pregnant  tube  is  not  unlike  the  inflammatory  swellings  of  the 
tube.  AYithout  other  evidences  of  pregnancy  it  would  be  impossible 
to  say,  with  assurance,  that  the  tube  is  pregnant  and  not  distended 
with  blood,  pus,  or  serum.  As  in  sactosalpinx,  the  pregnant  tube 
commonly  lies  low  at  the  side  of  or  behind  the  uterus. 

In  interstitial  pregnancy  the  gestation  sac  forms  with  the  uterus  a 
single  mass,  distinguished  by  a  more  elastic  consistency  when  con- 
trasted with  the  firmer  uterine  tissue. 

Exploratory  Vaginal  Incision. — Exploratory  vaginal  incision  has 
been  practised  by  Grandin  and  Spinelli  as  a  last  resort  in  the  making 
of  the  diagnosis.  If  an  exploratory  vaginal  incision  reveals  the  pres- 
ence of  an  ectopic  pregnancy  it  is  advised  that  the  operation  should 
immediately  follow. 

Exploratory  Abdominal  Incision. — Through  an  abdominal  incision  an 
accurate  diagnosis  can  be  made  and  the  operation  completed  without 
delay. 

Differential  Diagnosis. — Diagnosis  from  Pregnancy  in  a  Retroverted 
Uterus.  —  As  the  gestation  sac  of  an  ectopic  pregnancy  frequently 
lies  behind  the  uterus,  and  since  in  the  early  months  the  size,  form, 
and  consistency  of  the  uterus  of  an  ectopic  pregnancy  do  not  differ 
widely  from  that  of  intra-uterine  pregnancy,  confusion  is  likely  to 
arise.  Here  an  examination  under  anesthesia  is  of  the  greatest  value 
in  locating  the  uterus  and  in  clearly  outlining  it  apart  from  any  mass 
outside.  In  an  ectopic  pregnancy  lying  in  the  retro-uterine  space  the 
uterus  lies  well  forward,  and  by  its  form  and  consistency  can  usually 
be  outlined  apart  from  the  gestation  sac.  The  anatomical  distinctions 
between  the  pregnant  uterus  and  the  uterus  of  an  ectopic  pregnancy 
are  to  be  borne  in  mind.  In  uterine  pregnancy  the  uterus  is  more 
elastic  and  soft,  the  lower  uterine  segment  is  clearly  defined,  and  the 
transverse  diameter  is  relatively  increased.  The  possibility  of  a  com- 
bined uterine  and  extra-uterine  gestation  should  be  borne  in  mind. 


DIFFERENTIAL  DIAGNOSIS  159 

Uterine  Pregnancy  Complicated  with  a  Tubal  or  Ovarian  Swelling 
may  easily  be  confused  with  ectopic  pregnancy.  The  difficulties  are 
increased  when  the  uterus  is  enlarged  through  inflammation  (chronic 
metritis) .  Such  a  uterus,  when  gravid,  will  not  have  the  usual  elasticity 
and  softness  of  a  normal  pregnant  uterus.  On  the  other  hand,  the 
abdominal  wall  and  uterine  musculature  may  be  so  thin  as  to  give  the 
impression  that  the  fetus  lies  outside  the  uterus.  In  the  first  trimester 
the  physical  examination  of  the  uterus  alone  can  only  serve  to  sug- 
gest the  possibility  of  pregnancy.  When  from  the  size,  position,  con- 
sistency, and  contour  of  the  uterus  pregnancy  is  suspected,  the  next 
step  is  to  determine  whether  the  adnexse  are  enlarged  from  pregnancy, 
infection,  or  a  new-formation.  The  history  must  be  carefully  con- 
sidered, with  special  reference  on  the  one  hand  to  pregnancy  and  on 
the  other  to  infection.  The  pregnant  tube  is  usually  of  softer  consist- 
ency and  less  tender  than  is  an  inflammatory  swelling.  More  confusing 
still  is  the  occasional  occurrence  of  a  tubal  pregnancy  implanted  upon 
an  inflammatory  swelling  of  the  tube.  Here,  and  indeed  in  all  cases, 
the  history  will  be  of  the  greatest  value  in  making  the  differential 
diagnosis.  The  unilateral  involvement  of  the  tube  is  evidence  in  favor 
of  tubal  pregnancy,  though  bilateral  tubal  pregnancy  is  possible  and 
unilateral  involvement  of  the  tube  and  ovary  is  common.  A  pregnant 
tube  is  not  so  likely  to  be  fixed  by  adhesions  as  is  an  inflammatory 
swelling  of  the  tube,  and  tenderness  is  not  so  great. 

As  a  last  resort,  when  a  diagnosis  is  imperative,  a  sound  may  be 
passed  into  the  uterus,  or  if  there  is  evidence  to  support  the  belief 
that  an  abortion  has  occurred,  the  uterus  may  be  curetted  and  a 
microscopic  examination  made  of  the  scrapings.  If  decidua  and  fetal 
tissue  are  found  in  the  scrapings  the  pregnancy  must  have  been  intra- 
uterine. 

The  fact  that  no  decidua  is  found  is  not  conclusive  evidence  that 
tubal  pregnancy  cannot  possibly  be  present,  because  it  is  possible  that 
the  decidua  was  previously  expelled.  This  occurred  in  a  case  reported 
by  Tanneus. 

Diagnosis  from  Pelvic  Exudate,  Especially  When  following  upon  an 
Abortion. — A  period  of  amenorrhea  may  be  interrupted  by  uterine 
hemorrhage,  without  the  recognition  of  fetal  structures  in  the  escaped 
blood.  From  such  a  history  the  examining  physician  is  unable  to 
decide  whether  it  was  a  uterine  abortion  or  a  ruptured  tubal  pregnancy. 
If  an  examination  is  not  made  until  some  time  has  elapsed,  and  a 
mass  is  found  in  the  pelvis,  the  question  arises  as  to  whether  this  mass 
is  due  to  an  inflammatory  exudate  or  to  a  gestation  sac  and  the 
escaped  blood  of  a  ruptured  ectopic  pregnancy.  If  an  inflammatory 
exudate,  the  history  should  point  to  a  pelvic  infection  following  the 
abortion,  to  a  rise  of  temperature,  and  to  pain  in  the  pelvis.  The 
mass  should  be  firmly  fixed  and  tender.  In  ectopic  pregnancy  there 
is  less  tenderness  and  pain,  and  the  general  symptoms  of  sepsis  are  not 
present  unless  the  mass  has  become  infected.  A  very  good  general 
rule  is  that  in  a  pelvic  abscess  the  fever  and  high  pulse-rate  precede 


IGO  ECTOPIC  OR  EXTRA-UTERIXE  PREGNAXCY 

the  development  of  the  pehic  exudate,  while  in  ectopic  pregnancy  there 
is  no  fever  or  rise  of  pulse-rate  before  the  de^•elopment  of  the  tumor. 
Furthermore,  with  the  de^-elopment  of  the  inflammatory  exudate  the 
general  symptoms  of  infection  increase,  while  with  the  sudden  appear- 
ance of  an  escaped  mass  following  upon  the  rupture  of  a  gravid  tube 
the  temperature  is  likely  to  become  subnormal  and  be  later  followed 
by  a  moderate  rise  of  temperature. 

Finally,  an  exploratory  puncture  or  incision  through  the  vaginal 
wall  will  determine  the  true  nature  of  the  swelling.  If  a  pelvic  abscess 
develops  it  may  not  be  possible  to  determine  whether  it  was  derived 
from  an  inflammatory  exudate  or  from  a  secondary  infection  of  an 
ectopic  pregnancy.  In  the  removal  of  the  puSj  fetal  tissue  may  or 
may  not  be  discovered  either  by  the  naked  eye  or  by  the  microscope. 
The  presence  of  blood-clots  in  the  pus  is  highly  suggestive  of  tubal 
pregnancy. 

Diagnosis  from  Pregnancy  in  a  Bicomate  Uterus. — Pregnancy  in  a 
bicornate  uterus  may  closely  resemble  an  ectopic  pregnancy.  The 
diagnosis  may  be  clarified  by  the  discovery  of  a  septum  in  the  vagina 
or  cervix.  It  is  seldom  possible  to  palpate  the  round  ligament,  but 
if  it  is  found  attached  external  to  the  gestation  sac  the  pregnancy  is 
either  interstitial  or  in  a  horn  of  a  malformed  uterus;  if  the  round  liga- 
ment lies  internal  to  the  gestation  sac  a  bicornate  pregnancy  is  excluded. 

Diagnosis  from  Pregnancy  in  a  Rudimentary  Horn. — Pregnancy  in  a 
rudimentary  horn  cannot  be  distinguished  from  tubal  pregnancy  before 
opening  the  abdominal  cavity.  It  is  then  recognized  by  finding  the 
insertion  of  the  round  ligament  external  to  the  gestation  sac. 

Diagnosis  from  Ovarian  Tumors. — Ovarian  tumors  may  be  difficult 
to  distinguish  from  an  ectopic  pregnancy.  In  ovarian  tumors  the 
breasts  may  enlarge  and  secrete  colostrum,  and  there  may  be  morning 
sickness  and  amenorrhea.  With  the  aid  of  an  anesthetic  a  bimanual 
examination  should  determine  the  diagnosis.  As  a  rule  the  uterus  can 
be  clearly  outlined  distinct  from  the  ovarian  tumor,  and  is  found  not 
to  differ  from  the  normal  non-gravid  uterus. 

Rupture  of  an  ovarian  cyst  may  suggest  a  possible  rupture  of  an 
ectopic  pregnancy.  The  absence  of  a  history  of  pregnancy,  the  pres- 
ence of  a  long-standing  tumor,  and  the  absence  of  changes  in  the 
uterus  suggestive  of  pregnancy,  including  a  decidua,  should  suffice  for 
the  making  of  a  diagnosis. 

Torsion  of  the  pedicle  of  an  ovarian  cyst  may  give  rise  to  pain  and 
symptoms  of  internal  hemorrhage  not  unlike  those  of  a  ruptured. ectopic 
pregnancy.  A  consideration  of  the  points  referred  to  under  rupture 
of  an  ovarian  cyst  should  serve  in  excluding  rupture  of  an  ectopic 
pregnancy. 

An  ovarian  tumor  complicating  pregnancy  is  at  times  confusing  in 
the  diagnosis.  The  shape,  size,  and  consistency  of  the  uterus,  as  a  rule, 
serve  in  determining  the  presence  of  a  uterine  pregnancy.  The  great 
improbability  of  a  tubal  pregnancy  complicating  a  uterine  pregnancy, 
together  with  the  usual  signs  of  an  ovarian  cyst,  generally  clears  up 


DIFFERENTIAL  DIAGNOSIS 


161 


the  diagnosis.  If  the  cyst  is  large  it  will  be  observed  that  there  is  an 
absence  of  ballottement,  of  fetal  heart  tones,  and  of  fetal  movements 
in  what  is  suspected  of  being  a  gestation  sac. 

Diagnosis  from  Fibromyoma  of  the  Uteras. — Fibromyoma  of  the 
uterus  can  scarcely  be  mistaken  for  ectopic  pregnancy.  There  is  an 
absence  of  a  history  of  pregnancy,  and  the  uterus  shows  none  of  the 
characteristic  changes.  The  tumor  is  of  long  standing,  which  together 
with  its  firm  consistency  and  the  close  relation  of  the  uterus  to  the 
tumor  mass,  should  leave  little  doubt  as  to  the  diagnosis.  An  explor- 
atory curettage  of  the  uterus  will  fail  to  find  decidual  tissue. 


Fig.  77 


Left  tubal  pregnancy  operated  on  five  months  after  signs  of  life  had  disappeared.  The  superior 
surface  of  the  left  tube  is  still  visible  on  the  surface  of  the  sac.  The  left  ovary  was  visible  only  as  a 
bluish  flattened  patch  apparently  forming  a  part  of  the  sac  wall.  The  sac  developed  between  the  folds 
of  the  mesosalpinx  and  mesosigmoid.  The  patient  was  suffering  from  uterine  hemorrhage,  but  had 
never  been  seriously  ill.  There  had  never  been  signs  of  rupture,  and  the  whole  sac  was  dissected  intact 
from,  the  cornua  of  the  uterus.     (Jewett.) 


Diagnosis  from  Malignant  Diseases  of  the  Pelvis. — ]\Ialignant  disease 
of  the  pelvis,  by  its  irregular  outline,  may  suggest  an  ectopic  preg- 
nancy, and  the  more  so  when  it  occurs  in  the  "dodging  period."  The 
absence  of  the  signs  of  pregnancy  and  the  presence  of  general  signs  of 
malignancy  should  exclude  the  possiblity  of  ectopic  pregnancy. 

Diagnosis  from  Pelvic  Hematoma  and  Hematocele. — Pelvic  hematoma 
and  hematocele  not  due  to  ectopic  pregnancy  are  exceedingly  rare. 
Causes  other  than  ectopic  pregnancy  resulting  in  the  formation  of  a 
11 


162  ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 

hematoma  or  hematocele  are  obstructions  to  the  outflow  of  the  men- 
strual blood,  rupture  of  varicose  veins  in  the  broad  ligaments,  and  rup- 
ture of  an  ovarian  cyst  and  of  the  uterus.  In  determining  the  origin  of 
the  blood  mass  the  first  and  most  important  step  is  the  consideration 
of  pregnancy.  In  long-standing  cases  of  hematoma  and  hematocele 
following  upon  the  rupture  of  an  ectopic  pregnancy  it  may  be  impos- 
sible to  find  any  evidence  of  pregnancy  either  in  the  tube  or  in  the 
uterus. 

Diagnosis  from  Acute  Abdominal  Affections, — Of  all  acute  abdominal 
affections  in  woman,  ruptured  ectopic  pregnancy  is  the  most  important 
■  from  a  gynecological  point  of  view.  There  are  a  number  of  acute 
affections  of  the  abdominal  organs  which  have  very  similar  clinical 
manifestations,  and  it  is  imperative  that  a  diagnosis  be  made  at  the 
earliest  possible  moment  in  order  that  proper  surgical  measures  may 
be  instituted. 

The  importance  of  differentiating  these  various  lesions  will  justify  a 
thorough  consideration.  The  following  acute  abdominal  affections  may 
simulate  ectopic  pregnancy: 

1.  Appendicitis. 

2.  Intestinal  colic. 

3.  Renal  colic. 

4.  Hepatic  colic. 

5.  Internal  hernia. 

6.  Acute  pancreatitis. 

7.  Movable  kidney. 

8.  Rupture  of  a  gastric  or  duodenal  ulcer. 

In  differentiating  these  conditions  consideration  must  be  given, 
first,  to  the  previous  history,  then  to  the  present  complaints,  and 
finall}^  to  the  physical  examination. 

Appendicitis. — Appendicitis  in  its  onset  and  in  its  further  course 
may  very  closely  simulate  a  ruptured  tubal  pregnancy,  but  in  appen- 
dicitis there  are  none  of  the  general  and  local  signs  of  pregnancy. 
There  is  often  a  history  of  previous  attacks,  with  intervals  of  complete 
or  partial  freedom  from  pain  and  intestinal  disorder.  The  distress  is 
almost  always  confined  to  the  right  side,  while  in  ectopic  pregnancy 
it  is  often  referred  to  the  median  line  or  left  side. 

In  both  of  these  conditions  the  pain  appears  suddenly,  and  ma,y  be 
intense;  in  ectopic  pregnancy  it  may  be  momentary,  while  in  appen- 
dicitis it  usually  persists  throughout  the  attack.  The  sudden  pallor 
and  collapse  frequently  following  immediately  upon  the  rupture  of  a 
tubal  pregnancy  never  occur  in  appendicitis.  It  is  at  this  time  that  a 
most  suggestive  sign  appears — i.  e.,  uterine  hemorrhage  accompanied 
by  a  discharge  of  decidual  membrane.  In  such  an  event  there  can  be 
no  further  consideration  of  appendicitis.  Much  dependence  is  placed 
upon  the  finding  of  an  enlarged  soft  uterus  and  an  irregular  mass 
attached  to  it  at  the  side  or  lying  behind  the  uterus.  When  doubt 
exists,  the  uterus  may  be  explored  with  a  curet  and  the  scrapings 
examined  for  decidual  tissue. 


DIFFERENTIAL  DIAGNOSIS  163 

In  intraperitoneal  hemorrhages  from  rupture  of  the  gestation  sac 
the  abdomen  may  be  distended,  firm,  and  tender,  and  this  may  be 
associated  with  nausea,  vomiting,  rise  of  temperature,  and  leucocy- 
tosis.  Here  the  diagnosis  must  rely  almost  wholly  upon  the  previous 
history. 

Intestinal  Colic. — Intestinal  colic  begins  with  griping  abdominal 
pains,  vomiting,  and  diarrhea.  This  may  lead  on  to  collapse.  Often 
a  cause  for  the  intestinal  colic  can  be  elicited.  Lead  colic  is  rarely  seen 
in  women.  The  blue  line  on  the  gums,  constipation,  and  colicky  pains 
about  the  umbilicus  found  in  a  patient  working  with  lead  will  fix  the 
diagnosis  of  lead  colic. 

Renal  Colic. — Renal  colic  should  not  be  difficult  to  diagnosticate  from 
rupture  of  an  ectopic  pregnancy.  When  occurring  during  the  course 
of  a  uterine  pregnancy,  renal  colic  may  excite  suspicion  of  a  ruptured 
tubal  pregnancy.  In  renal  colic  the  pain  is  severe  and  increasing,  it  is 
sharp  and  radiates  to  the  groin  and  thigh.  Vomiting,  sudden  rise  of 
temperature,  cold  sweats,  and  collapse  are  frequent  accompaniments. 
Watching  the  urine  closely,  blood  will  be  seen  to  appear,  though  the 
microscope  may  be  required  to  detect  it.  All  urine  voided  should  be 
searched  for  the  stone.  These  events,  in  the  absence  of  an  extra-uterine 
pelvic  mass,  will  serve  for  a  diagnosis.  A  history  of  previous  attacks 
will  be  highly  suggestive.  It  is  possible  that  the  presence  and  location 
of  the  stone  can  be  determined  by  means  of  the  .r-ray. 

Hepatic  Colic. — Hepatic  colic  frequently  arises  after  the  childbearing 
period.  When  associated  with  pregnancy  the  rupture  of  an  ectopic 
pregnancy  would  naturally  be  suggested.  Flatulent  dyspepsia  has 
usually  been  a  more  or  less  constant  complaint.  Pain  is  referred  to 
the  right  hypochondrium,  epigastrium,  right  shoulder,  and  back. 
Associated  with  this  is  epigastric  tenderness,  nausea,  and  vomiting. 
If  the  stone  passes  into  the  common  bile  duct  there  will  probably  be 
jaundice,  clay-colored  stools,  and  bile  in  the  urine.  The  gall-bladder 
may  be  distended  and  tender.  If  gallstones  are  passed  by  the  bowel 
or  seen  by  the  a:-ray  the  diagnosis  is  established.  There  is  little  in 
such  a  history  to  suggest  rupture  of  an  ectopic  gestation  sac,  and  yet 
mistakes  have  been  made. 

Internal  Hernia. — Internal  hernia  usually  begins  with  pain,  which 
may  be  severe  or  slight,  and  even  absent.  Vomiting  is  often  the  earliest 
sign,  and  this  becomes  stercoraceous.  There  is  no  gas  or  fecal  matter 
passed  by  the  bowel.  Indican  is  present  in  the  urine  in  large  quantities. 
None  of  the  symptoms  points  to  the  pelvis,  and  a  vaginal  examination 
excludes  the  possibility  of  ectopic  pregnancy. 

Acute  Pancreatitis. — Acute  pancreatitis  is  frequently  regarded  as  an 
aggravated  form  of  indigestion  until  the  patient  is  seized  with  severe 
pain  in  the  epigastrium,  repeated  vomiting,  and  collapse.  The  epi- 
gastrium is  tender  on  pressure,  though  there  is  no  distention.  Collapse 
may  follow  upon  persistent  vomiting.  There  is  little  possibility  of 
mistaking  such  a  condition  for  ectopic  pregnancy,  though  the  abdominal 
pain,  vomiting,  and  collapse  occurring  in  a  woman  of  the  childbearing 


1G4  ECTOPIC  OR  EXTRA-UTERINE  PREGNAXCY 

period  should  first  of  all  suggest  an  abnormal  condition  of  pregnancy 
and  call  for  an  immediate  physical  examination. 

Movable  Kidney. — ^Movable  kidney  is  seldom  associated  with  such 
intense  pain  and  shock  as  to  become  a  serious,  acute  abdominal  affection. 
The  pain  is  usually  referred  to  the  right  h\-pochondrium,  and  may  be 
associated  with  vomiting  and  shock.  Palpating  a  firm,  tender,  kidney- 
shaped  tumor  in  the  right  lumbar  or  iliac  space  and  the  ability  to 
readily  force  this  tumor  beneath  the  right  costal  arch  will  determine 
the  diagnosis.  A  history  of  previous  lesser  pains  and  a  dragging  sensa- 
tion coming  on  in  the  right  hypochondrium  shortly  after  rising,  together 
with  relief  upon  lying  down,  will  suggest  the  diagnosis. 

Rupture  of  Gastric  or  Duodenal  Ulcer. — Rupture  of  a  gastric  or 
duodenal  ulcer  will  almost  always  occur  after  a  meal  and  upon  exertion. 
There  is  a  previous  history  of  anemia  and  indigestion  in  nearly  all 
cases.  The  vomiting  of  blood  and  the  occurrence  of  gastric  pains  are 
frequent  events.  The  history  and  a  pelvic  examination  will  exclude 
ectopic  pregnancy. 

Treatment. — Extra-uterine  pregnancy  is  one  of  the  most  formidable 
of  surgical  emergencies  and  in  the  majority  of  instances  calls  for  early 
surgical  interference  in  the  interest  of  the  mother. 

The  observations  of  Werth  ha^'e  an  important  bearing  upon  the 
treatment  of  extra-uterine  pregnancy.  He  has  shown  that  after  the 
death  of  the  fetus,  either  before  or  after  the  escape  of  the  ovum  from 
the  tube,  the  chorionic  epithelium  (Langhans'  cells  and  syncytium) 
may  continue  to  proliferate  and  to  invade  maternal  bloodvessels  in  the 
wall  of  the  tube,  thereby  inducing  hemorrhages.  Furthermore,  a  par- 
tial abortion,  where  the  ovum  has  partly  escaped  from  the  fimbriated 
end  of  the  tube,  may  occasion  repeated  hemorrhages  as  was  well 
illustrated  in  one  of  the  author's  cases.  These  facts  speak  for  the 
uncertainty  of  tentative  treatment. 

Unruptured  Tubal  Pregnancy. — The  only  safe  rtde  to  adopt  in  the 
interest  of  the  mother  is  to  remove  the  imruptured  gestation  sac  at 
the  earliest  possible  moment.  ^Mien  the  pregnancy  is  far  advanced, 
delay  may  be  ^countenanced  in  the  interest  of  the  child,  but  only  with 
full  understanding  of  the  dangers  involved. 

As  soon  as  an  unruptured  tubal  pregnancy  is  recognized,  or  diag- 
nosticated with  a  reasonable  degree  of  certainty,  the  patient  must  be 
put  to  rest  and  no  time  lost  in  the  preparations  for  operation.  The 
question  of  the  advisability  of  removing  the  patient  to  a  hospital  must 
be  determined  by  the  conditions  governing  the  patient.  If  the  distance 
is  not  too  great,  the  means  of  transportation  such  as  will  permit  of 
moving  the  patient  with  all  possible  care  and  the  general  resistance  of 
the  patient  is  sufficient  for  the  task,  it  would  seem  advisable  to  convey 
the  patient  to  a  hospital  where  her  interests  can  be  best  safeguarded. 
However,  it  is  best  to  operate  in  the  home  if  to  move  the  patient 
entails  great  risk. 

In  the  removal  of  the  gestation  sac  the  abdominal  route  should  be 
chosen. 


TREAT  MEXT  165 

\Yhen  the  fetus  and  its  membranes  are  located  at  the  outer  end  of 
the  tube  and  can  be  removed  without  sacrificing  the  tube,  some 
authorities  have  advised  conservatism.  ^Miile  such  a  procedure 
is  theoretically  conse^vati^■e,  there  is  always  the  question  of  possible 
infection  and  hemorrhage  on  the  one  hand  and  of  the  leaving  of  a 
disabled  and  offending  tube  on  the  other.  It  is  the  author's  preference 
to  remove  the  entire  tube  together  with  the  ovum. 

The  anatomical  findings  present  so  many  variations  that  it  is  quite 
impossible  to  describe  a  technic  which  wUl  be  of  universal  application. 
The  general  principles  are  as  follows: 

A  median  abdominal  incision  is  made  of  a  length  sufficient  to  deliver 
the  gestation  sac  and  its  contents  intact;  adhesions  binding  the 
gestation  sac  to  surrounding  structures  are  broken  up,  taking  care 
not  to  break  the  gestation  sac;  the  tube  and  its  contents  are  removed 
en  masse;  all  bleeding  vessels  are  firmly  secured  and  the  raAv  surfaces 
covered  with  peritoneum.  In  the  absence  of  sepsis  and  oozing  surfaces 
the  abdomen  is  closed  without  drainage.  When  drainage  is  established 
it  is  best  to  make  an  opening  through  the  cul-de-sac  of  Douglas  into 
the  vagina,  and  through  this  to  carry  the  end  of  a  roll  of  antiseptic 
gauze,  leaving  the  remaining  portion  of  the  gauze  snugly  packed  into 
the  space  previorsy'  occupied  by  the  pregnant  tube;  the- abdominal 
incision  is  then  closed.  The  drainage  is  left  about  forty-eight  hours, 
when  it  is  removed  through  the  vagina.  As  a  precautionary  measure 
against  the  occurrence  of  hemorrhage  while  removing  the  tube,  it  is 
weU  to  ligate  or  clamp  the  ovarian  vessels  near  the  uterine  cornua  and 
between  the  fimbriated  end  of  the  tube  and  brim  of  the  pelvis.  Having 
secured  these  vessels  the  tube  or  tube  and  ovary  may  be  removed  by 
excising  the  uterine  end  of  the  tube  from  the  coinua,  then  with  the 
scissors  cutting  along  the  lower  circumference  of  the  tube  throughout 
its  entire  length;  thus  completely  removing  the  tube  from  its  attach- 
ments and  leaving  the  cut  edges  of  the  broad  ligament  to  be  whipped 
over  with  a  running  suture  of  Xo.  1  plain  catgut. 

The  ovary  or  any  part  of  it  should  not  be  sacrificed  unless  diseased. 
After  the  tube  is  removed,  all  bleeding  points  controlled  by  ligatures 
and  the  raw  surfaces  cx)vered  by  peritoneum,  the  surgeon  proceeds 
to  correct,  as  far  as  possible,  all  associated  lesions  in  the  abdomen: 
In  nearly  all  instances  the  position  of  the  uterus  must  be  corrected; 
this  is  usually  accomplished  by  Ioo])ing  the  round  ligaments  behind  the 
fundus. 

At  the  Time  of  Rupture. — "When  a  case  is  seen  at  the  time  of  rupture 
the  following  questions  present  themselves:  Is  immediate  operation 
indicated?  Is  an  immediate  operation  imperative?  Will  the  patient 
be  in  better  condition  for  operation  after  a  variable  period  of  rest  and 
stimulation?  These  questions  can  only  be  determined  after  carefully 
considering  all  conditions  pertaining  to  the  physical  condition  of  the 
patient  and  the  preparedness  of  the  stirgeon  for  operation.  The  essen- 
tial principles  underlying  the  solution  of  the  problem  are  as  follows: 

As  a  general  proposition  all  cases  seen  near  the  time  of  rupture  or 


166  ECTOPIC  OR  EXTRA-UTERIXE  PREGXAXCY 

abortion  of  the  tube  call  for  early  but  not  immediate  operation.  This 
is  imperative  in  view  of  the  great  dangers  of  secondary  hemorrhage 
which  may  prove  fatal,  and  of  ill  health  which  often  results  from  too 
long  delay.  While  it  is  true  that  the  primary  hemorrhage  is  seldom 
fatal,  it  is  equally  true  that  there  is  no  possibility  of  predicting  the 
possible  occurrence  of  secondary  hemorrhage,  much  less  the  time  of 
its  occurrence  and  the  possible  consequences.  Hence  the  inadvisability 
of  unnecessary  delay  after  the  onset  of  hemorrhage. 

When  the  patient  is  found  in  a  state  of  great  depression  delay  may 
be  countenanced.  This  the  author  has  done  in  three  instances  where 
a  large  amount  of  blood  had  escaped  into  the  abdominal  cavity  and 
the  patients  were  profoundly  depressed.  Xo  time  was  lost  in  making 
ready  for  operation,  but  while  the  preparations  were  being  made  the 
patients  were  stimulated  and  carefully  watched.  They  responded 
readily  to  stimulation  and  were  carried  safely  through  the  period  of 
depression  before  the  operation  was  undertaken.  Had  they  not  so 
readily  responded  they  would  have  been  operated  upon  without  delay 
and  without  general  anesthesia.  The  author  is  in  accord  with  Pro- 
chownick,  who  concludes  that  early  operative  interference  in  these 
cases  is  the  best  and  most  certain  form  of  conservatism.  In  50  lapa- 
rotomies performed  by  Prochownick  good  results  were  obtained  in  41, 
and  in  18  vaginal  incisions,  12  complete  recoveries  ensued.  Of  the  cases 
treated  expectantly  some  were  satisfactorily  relieved,  but  the  majority 
failed  to  attain  good  health.  Out  of  39  laparotomies,  21  (53  per  cent.) 
subsequently  became  pregnant,  while  in  those  treated  expectantly 
50  per  cent,  became  pregnant.  In  this  connection  it  is  of  interest  to 
note  the  advice  of  Werth,  who  councils  immediate  surgical  intervention 
regardless  of  the  degree  of  shock.  He  argues  that  the  operation  is 
short,  that  the  anesthetic  is  given  sparingly,  if  at  all,  and  that  he  has 
observed  the  pulse  to  improve  immediately  after  these  operations. 

^^^len  the  rupture  is  recent  it  would  seem  wise  to  always  choose 
the  abdominal  route  in  preference  to  the  vaginal.  By  doing  this  the 
affected  tube  can  be  dealt  with  and  there  is  a  minimum  risk  of  hemor- 
rhage. In  one  of  the  author's  cases,  in  which  vaginal  drainage  was 
established,  an  intraperitoneal  hemorrhage  was  excited  by  the  manip- 
ulations and  was  all  but  fatal.  In  an  operation  by  Schauta,  of  Vienna, 
which  the  author  witnessed,  the  vaginal  incision  and  drainage  were 
hurriedly  followed  by  an  abdominal  incision  for  the  control  of  an 
intraperitoneal  hemorrhage. 

As  soon  as  the  abdomen  is  opened,  if  there  is  no  fresh  bleeding,  the 
escaped  blood  is  removed  with  swabs  and  the  tube  together  with  the 
ovum  are  removed  as  described  above.  If  there  is  fresh  hemorrhage  at 
the  time  of  operation  there  should  be  no  loss  of  time  in  controlling  the 
uterine  and  ovarian  arteries  with  clamp  or  ligature.  The  abdominal 
incision  should  be  long  enough  to  permit  of  ready  access  to  the  field 
of  operation.  The  escaped  blood  may  mask  the  condition,  and  if  new 
blood  is  being  constantly  added  to  that  which  has  escaped,  the  operator 
should  not  attempt  to  cleanse  the  field  of  operation  before  removing 


T  RE  ATM  EXT  167 

the  tube,  but  should  grasp  the  uterus  with  his  hand.  With  this  as  a 
starting  point  he  should  pass  the  hand  on  either  side  until  the  preg- 
nant tube  is  recognized;  this  is  grasped,  freed  of  its  adhesions,  and 
pulled  into  view.  A  clamp  is  then  placed  on  either  side  of  the  gesta- 
tion sac  to  control  the  ovarian  arteries.  The  escaped  blood  is  then 
removed  with  swabs  and  the  operation  proceeds  as  already  described. 

\Mien  there  is  great  depression  too  much  time  should  not  be  con- 
sumed in  the  various  niceties  of  the  peritoneal  toilet  and  in  correcting 
other  conditions  within  the  abdomen. 

At  the  meeting  of  the  American  Gynecological  Society  in  1912  there 
was  a  symposium  on  the  management  of  intra-abdominal  hemorrhage 
in  tubal  pregnancy.  From  the  discussion  the  following  deductions  are 
presented  as  an  expression  of  the  opinion  of  the  society: 

1.  Neither  undue  haste  nor  }'et  unnecessary  delay  should  be  practised 
in  dealing  with  these  cases,  because  not  more  than  5  per  cent,  die  from 
hemorrhage,  and,  on  the  other  hand,  too  long  delay  in  interference 
may  lead  to  permanent  disabilities. 

2.  An  immediate  operation  does  not  contribute  largely  to  shock 
if  done  skilfully.  The  added  depression  as  the  result  of  the  operation 
can  usually  be  eliminated  by  the  timely  administration  of  salt  solution 
and  other  stimulants. 

3.  The  conclusions  drawn  from  a  comparison  of  cases  operated 
immediately  with  those  operated  at  a  much  later  date  are  liable  to 
be  misleading  in  that  the  former  group  presents  a  greater  number  of 
serious  cases. 

4.  In  the  hands  of  the  unskilled  and  when  the  surroundings  are 
unfavorable  to  good  surgery  the  deferred  operation  is  preferred,  with 
the  exception  of  the  few  cases  which  faU  to  react  under  stimulation. 

5.  No  definite  rule  can  be  adopted  for  the  management  of  aU  cases. 
It  is  the  business  of  the  surgeon  to  immediately  prepare  for  operation 
while  restorative  measures  are  being  applied.  If  the  patient  reacts 
the  operation  may  be  delayed;  if  she  does  not  react,  no  time  should 
be  lost  in  opening  the  abdomen. 

After  Rupture. — When  the  case  is  seen  late  after  rupture  the  question 
of  tentative  treatment  may  be  justly  considered.  Unquestionably, 
cases  of  ruptured  tubal  pregnancy  frec{uently  resolve  themselves  into 
a  perfectly  normal  state  and  may  require  no  surgical  intervention. 
However,  it  is  not  possible  in  any  given  case  to  predict  such  a  result 
with  certainty.  There  is  always  the  possible  danger  of  some  untoward 
event  which  may  jeopardize  the  life  and  health  of  the  patient.  It  is 
for  such  reasons  that  tentative  treatment  for  ruptured  tubal  pregnancy 
should  not  long  be  entertained,  and  only  so  when  the  patient  is  under 
close  observation.  The  dangers  arising  out  of  the  escaped  blood  and 
gestation  sac  are  discussed  on  page  166. 

Managemext  of  Exd  Stages. — The  management  of  the  end  stages 
of  ruptured  tubal  pregnancy  are  here  briefly  outlined: 

Formation  of  a  Hematoma. — If  a  blood  mass  is  found  in  the  pelvis, 
and  the  history  points  to  its  existence  for  some  time,  it  is  not  wise  to 


1G8  ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 

council  further  delay.  The  likelihood  of  an  indefinite  delay  in  the 
absorption  of  the  escaped  blood,  or  of  the  development  of  a  pelvic 
abscess,  or,  what  is  more  likely,  of  the  formation  of  pelvic  adhesions, 
speak  for  the  evacuation  of  the  escaped  blood  without  untlue  delay. 

If  the  escaped  blood  can  be  readily  reached  through  a  vaginal  incision 
this  route  should  be  preferred  to  the  abdominal. 

Vaginal  drainage  is  only  applicable  to  old  cases  in  which  there  is 
little  danger  of  exciting  fresh  hemorrhage. 

The  disadvantage  of  vaginal  drainage  in  such  cases  is  apparent. 
It  is  not  possible  to  deal  carefully  with  adhesions  to  coils  of  bowel 
nor  to  be  as  conservative  with  the  ovary  as  by  the  abdominal  route, 
and  it  is  never  possible  to  say  with  assurance  that  the  placental  tissue 
has  wholly  escaped  from  the  tube.  As  long  as  the  chorion  remains  in 
the  tube  there  is  danger  of  secondary  hemorrhage  from  the  continued 
growth  of  the  epithelium  of  the  chorion  into  the  bloodvessels  of  the 
tube  wall.  For  these  reasons  some  authorities  advise  operating  through 
the  abdomen  when  infection  of  the  blood  mass  can  be  excluded. 

Before  establishing  drainage  the  position,  size,  and  relation  of  the 
hematoma  to  the  pelvic  organs  must  be  clearly  defined  by  a  bimanual 
examination  under  anesthesia.  The  cervix  is  grasped  with  a  vulsellum 
forceps  and  traction  is  made  by  an  assistant  downward  and  forward. 
The  posterior  wall  of  the  vagina  is  grasped  about  one  inch  from  the 
cervix  by  a  long  rat-tooth  tissue  forceps,  and  with  long  sharp-pointed 
scissors  the  vaginal  wall  is  incised  laterally  immediately  behind  the 
cervix  for  a  distance  of  one  inch.  The  index-finger  is  then  inserted  into 
the  incision  and  in  the  direction  of  the  blood  mass.  In  some  instances 
the  finger  cannot  be  forced  into  the  hematoma  and  long  blunt  forceps 
or  scissors  are  directed  in  advance  of  the  finger.  This  is  a  dangerous 
procedure  and  should  be  carried  out  with  great  caution.  When  the 
clotted  blood  makes  its  appearance  through  the  incision  the  wound 
is  carefully  spread  with  the  fingers  to  permit  free  drainage.  With  the 
fingers  or  with  small  swabs  the  blood-clots  are  wholly  removed.  Then 
follows  the  packing  of  the  cavity  and  vagina  with  a  long  strip  of  iodo- 
form gauze.  No  sutures  or  ligatures  are  required.  If  irrigation  of 
the  cavity  is  made  it  should  be  done  under  low  pressure  and  with 
sterile  normal  salt  solution  at  a  temperature  of  110°  to  114°  F. 

The  author  has  operated  upon  ten  cases  in  this  manner,  and  in  every 
instance  a  perfect  result  was  obtained  without  suppuration.  In  two 
of  the  cases  a  second  and  in  one  a  third  drainage  with  irrigation  was 
necessary  because  of  the  untimely  closure  of  the  incision. 

The  after-treatment  of  these  cases  consists  in  enjoining  rest  in  bed 
until  such  time  as  the  cavity  has  closed,  which  rarely  exceeds  four 
weeks;  of  removing  the  pack  forty-eight  hours  after  its  insertion,  to 
be  followed  by  an  antiseptic  vaginal  douche;  to  give  such  stimulation 
as  may  be  required,  and  to  nourish  the  patient  in  every  possible  way. 

The  possible  development  of  adhesions  subsequent  to  the  closure 
of  the  cavity  occupied  by  the  blood  must  not  be  disregarded,  and  when 
noted  they  are  to  be  dealt  with  by  the  application  of  hot  vaginal 


TREATMENT  169 

douches,  glycerin  and  icthyol  tampons,  and  pelvic  massage  according 
to  the  principles  laid  down.    See  Chapter  XI. 

Suppuration. — ^When  the  escaped  blood  becomes  converted  into  an 
abscess  no  time  should  be  lost  in  draining  the  abscess  through  the 
vagina. 

The  author  recently  performed  an  operation  in  which  not  only  a 
pelvic  abscess  developed  out  of  a  ruptured  tubal  pregnancy,  but  a 
general  suppurative  peritonitis  followed. 

After  draining  such  a  pelvic  abscess,  great  caution  must  be  exercised 
in  all  the  manipulations  for  fear  of  breaking  down  the  protective  wall 
of  adhesions  which  safeguards  the  general  peritoneal  cavity.  Too 
vigorous  manipulations  with  swabs,  fingers  and  instruments  within  the 
abscess  cavity  have  been  responsible  for  the  development  of  general 
peritonitis.  The  irrigation  of  the  abscess  cavity  at  the  time  of  the 
operation  should  also  be  condemned  for  the  same  reason. 

After  the  abscess  has  been  drained  it  is  the  author's  custom  to  pack 
the  cavity  and  the  vagina  with  a  single  long  strip  of  iodoform  gauze. 
These  strips  are  usually  removed  thirty-six  to  forty-eight  hours  after 
the  operation  and  a  vaginal  douche  of  formalin,  1  to  4000,  given  at  low 
pressure.  Subsequently,  if  the  drainage  is  not  good,  as  evidenced  by 
increased  pain  in  the  pelvis,  rise  of  pulse-rate  and  temperature,  the 
original  incision  may  be  spread  with  forceps  or  fingers,  and  the  cavity 
irrigated  with  sterile  normal  salt  solution.  If  an  accumulation  of  pus 
is  detected  in  the  pelvis  which  will  empty  by  this  method  alone,  it 
should  be  opened  by  the  finger  or  by  advancing  forceps,  and  possibly 
again  packed  with  gauze. 

There  should  be  no  thought  of  opening  the  abdominal  cavity  so 
long  as  the  pus  is  confined  to  the  pelvis  and  can  be  drained  through 
the  vagina.  There  is  time  enough  for  an  abdominal  section  after  the 
pus  is  well  drained,  and  the  acute  stage  of  the  pelvic  inflammation  has 
long  passed.  Happily,  in  many  cases  there  is  no  need  of  a  subsequent 
abdominal  section. 

Secondary  Hemorrhage. — When  there  has  been  a  secondary  hemor- 
rhage no  time  should  be  lost  in  performing  an  abdominal  section. 
Vaginal  incision  is  not  countenanced  in  view  of  the  possibility  of  having 
to  contend  with  an  uncontrollable  hemorrhage.  Delay  in  interfering 
is  likewise  inadvisable,  for  it  is  assumed  that  a  third  and  possible  fatal 
hemorrhage  may  ensue. 

Growth  of  Fetus  after  Rupture. — If  the  escaped  mass  of  blood  and 
ovum  slowly  increases  in  size  and  it  is  thought  highly  probable  that 
the  fetus  is  living,  the  proper  procedure  is  to  open  the  abdominal 
cavity  and  remove  the  tube  and  escaped  mass.  In  exceptional  cases 
it  may  be  demonstrated  by  the  examination  that  the  ovum  lies  within 
the  broad  ligament.  In  such  an  event  a  vaginal  section  would  be  the 
method  of  choice.  The  precaution,  however,  should  be  taken  to  pre- 
pare previously  for  an  abdominal  section  in  view  of  possible  failure  to 
complete  the  operation  through  a  vaginal  incision. 

While  the  vaginal  route  has  been  chosen  for  the  removal  of  advanced 


170  ECTOPIC  OR  EXTRA-UTERIXE  PREGNANCY 

extra-uterine  gestation  the  difBciilties  are  great  and  should  only  be 
chosen  in  preference  to  the  abdominal  route  when  there  is  suppuration. 

Treatment  of  Intraligamentary  Extra-uterine  Pregnancy.  —  When  the 
diagnosis  is  made  in  advance  of  the  operation  an  extraperitoneal  route 
should  be  chosen;  this  should  be  by  the  vagina  or  immediately  above 
Poupart's  ligament,  depending  upon  the  location  of  the  gestation  sac. 
If  the  sac  is  located  low  in  the  pelvis  the  vaginal  route  is  chosen,  if 
high  upon  the  anterior  wall,  the  incision  should  be  made  immediately 
above  Poupart's  ligament.  Unless  far  advanced  in  pregnancy  one  of 
these  routes  should  be  chosen  even  after  an  abdominal  incision  has 
been  made  and  the  gestation  found  lying  extraperitoneal. 

Treatment  of  Interstitial  Pregnancy. — Kelly  advises  the  making  of  a 
gentle  effort  to  open  the  sac  wall  into  the  uterine  cavity  by  dilating 
the  cervix  and  using  a  sound.  Such  a  procedure  would  seem  to  be 
very  uncertain  and  hazardous. 

The  difficulties  involved  in  accurately  locating  the  gestation  sac  in 
the  horn  of  the  uterus  before  making  an  abdominal  incision  are  great, 
and  it  would  seem  to  the  author  that  in  view  of  the  opportunities  for 
infection  the  greatest  safety  lies  in  favor  of  excismg  the  gestation  sac 
and  tube  from  the  uterus  through  an  abdominal  incision. 

Treatment  of  Advanced  Extra-uterine  Pregnancy. — Xo  consideration 
should  be  given  the  child  prior  to  the  period  of  viability.  The  dangers 
attending  the  presence  of  a  living  fetus  within  the  abdomen,  but  not 
resident  in  the  uterus,  are  of  such  a  serious  nature  as  to  brook  no  delay 
in  its  removal. 

After  the  period  of  viability  the  question  may  justly  arise  as  to  the 
advisability  of  allowing  pregnancy  to  advance  to  near  term  in  the 
interest  of  the  child.  The  author  very  much  questions  the  wisdom 
of  such  a  course.  A  living  and  well-developed  child  is  occasionally 
delivered  through  the  abdomen,  but  such  instances  are  very  rare.  It 
is  far  more  likely  that  the  mother's  life  will  be  jeopardized  in  the  effort, 
or  that  the  life  of  the  child  will  not  be  saved.  Too  often  such  babies 
are  poorly  developed  and  survive  for  only  a  short  time. 

At  all  events,  if  such  an  expectant  course  is  to  be  pursued  in  the 
latter  half  of  pregnancy,  it  should  be  by  the  expressed  wish  of  the 
mother  and  friends  after  a  full  understanding  of  the  attending  dangers. 
Throughout  this  period  of  watchful  expectancy  the  patient  must  always 
be  under  masterly  control,  with  conditions  such  as  will  permit  of 
immediate  surgical  intervention  should  occasion  arise. 

When  the  ectopic  pregnancy  is  advanced  into  the  second  semester 
it  is  of  the  highest  importance  to  determine  the  life  or  death  of  the 
fetus.  Upon  this  decision  will  depend  the  disposition  that  will  be  made 
of  the  placenta.  If  the  fetus  is  living  the  removal  of  the  placenta 
together  with  the  fetus  becomes  a  dangerous  procedure,  because  of  the 
accompanying  hemorrhage.  In  the  presence  of  a  dead  fetus  the  placental 
sinuses  are  plugged  with  coagula  and  no  serious  hemorrhage  is  antici- 
pated in  its  removal.  In  the  majority  of  cases  the  life  or  death  of  the 
fetus  is  not  determined  before  opening  the  abdomen. 


TREATMENT  171 

If  the  fetus  is  dead  it  should  be  removed  together  with  the  placenta. 
If  the  fetus  is  living  and  the  placenta  is  so  attached  to  the  uterus, 
broad  ligaments  or  tubal  wall  that  the  bloodvessels  leading  to  the 
placenta  may  be  securely  ligated,  the  placenta  may  be  removed  along 
w4th  the  fetus.  If  not  so  attached  the  cord  is  ligated  and  severed  close 
to  the  placenta,  the  fetus  removed,  and  an  iodoform  gauze  pack  carried 
down  upon  the  placenta.  This  gauze  pack  is  removed  at  the  end  of 
forty-eight  hours  and  the  placenta  left  to  be  discharged  piecemeal 
through  the  wound  or  removed  en  masse  at  the  end  of  the  forty-eight 
hours. 

In  such  cases  there  is  always  the  danger  of  hemorrhage  from  the 
placental  site,  and  the  infection  of  the  placental  mass  prolongs  the 
convalescence  and  may  lead  to  a  fatal  issue.  Whenever  possible  it  is  a 
wise  precaution  to  ligate  the  ovarian  and  uterine  vessels  on  the  affected 
side.  The  greatest  care  must  be  exercised  in  securing  by  ligatures  all 
bleeding  vessels  and  in  maintaining  the  strictest  precautions  against 
infection. 

As  far  as  possible  the  general  peritoneal  cavity  must  be  protected 
against  possible  contamination.  This  is  done  by  walling  off  the  peri- 
toneal cavity  with  sterile  packs  of  gauze  while  the  operation  is  in 
progress,  and  when  the  placenta  is  left,  by  stitching  the  amniotic  sac 
to  the  peritoneum  of  the  abdominal  incision. 

Because  of  the  great  danger  of  secondary  hemorrhage  and  sepsis 
it  would  be  hazardous  to  close  the  abdominal  incision  after  removing 
the  fetus,  leaving  the  placenta  to  be  absorbed. 

If  extensive  adhesions  exist  they  are  carefully  separated,  and  if 
the  raw  surfaces  cannot  be  well  covered  with  peritoneum  or  thor- 
oughly charred  with  a  thermocautery  it  may  be  well  to  establish 
drainage.  This  is  best  done  by  carrying  the  end  of  a  long  strip  of 
iodoform  gauze  through  the  cul-de-sac  into  the  vagina  and  packing 
the  pelvis. 

Treatment  of  Combined  Extra-uterine  and  Intra-uterine  Pregnancy. — 
Many  cases  have  been  reported  in  which  a  lithopedeon  of  long  standing 
has  remained  in  the  peritoneal  cavity  without  disturbing  subsequent 
uterine  pregnancies.  They  have  been  known,  however,  to  necessitate 
the  induction  of  abortion  and  to  obstruct  labor  at  full  term. 

When  the  tubal  pregnancy  is  active  at  the  time  of  uterine  pregnancy 
the  indication  for  interference  is  imperative.  W^hile  an  effort  shoidd 
be  made  to  save  the  child  in  utero,  the  presence  of  a  tubal  pregnancy 
brooks  no  delay. 

The  rule  is  to  deal  with  the  tubal  pregnancy  along  the  lines  already 
laid  down  and  to  prevent,  if  possible,  the  interruption  of  the  uterine 
pregnancy.  It  is  always  hazardous  to  attempt  an  immediate  delivery 
of  the  fetus  in  utero. 

Treatment  of  Ovarian  Pregnancy. — This  does  not  differ  essentially 
from  that  of  tubal  pregnancy. 

Treatment  of  Pregnancy  in  a  Rudimentary  Horn  of  the  Uterus. — The 
operation  does  not  differ  essentially  from  that  described  for  tubal 


172 


ECTOPIC  OR  EXTRA-UTERINE  PREGNANCY 


pregnancy.    As  a  rule  the  rudimentary  horn  has  a  well-marked  pedicle 
which  is  dealt  with  as  is  the  uterine  end  of  the  tube. 


Fig.  7,S 


A  case  of  ovarian  pregnancy.    A,  stroma  of  ovary;  B,  cut  edge  of  attachment;  C,  placental  tissue; 
D,  seat  of  rupture.     (Banks,  in  Jour,  of  Obst.  and  Gyn.  of  British  Empire,  April,  1912.) 


Mortality  of  Extra-uterine  Pregnancy. — In  22  cases  of  tubal  preg- 
nancy the  author  has  had  2  fatalities;  1  a  ruptured  tubal  pregnancy 
which  was  not  seen  until  a  general  suppurative  peritonitis  had 
developed,  and  an  intraligamentary  pregnancy  ruptured  into  the 
general  peritoneal  cavity  with  the  escape  of  a  large  amount  of  blood. 
Death  resulted  from  surgical  shock.  The  20  cases  which  recovered 
were  of  the  following  varieties:  early  unruptured  tubal  pregnancies,  4; 
early  tubal  abortions,  3;  early  intraperitoneal  ruptures,  7;  early  intra- 
ligamentary ruptures  of  the  pregnant  tube,  6. 

In  all  the  cases  both  the  tube  and  the  gestation  sac  were  removed. 
The  ovary  of  the  affected  side  was  saved  in  more  than  half  the 
cases. 

Schauta  reported  241  cases  not  operated  in  which  there  was  'a  mor- 
tality of  68.8  per  cent. 

In  the  Johns  Hopkins  Hospital  there  were  139  cases  reported  by  Kelly, 
of  which  6  died. 

It  will  be  of  interest  to  note  a  comparison  of  the  results  in  the 
conservative  and  radical  methods  of  treatment  of  extra-uterine 
pregnancy. 

Von  Scanzoni  treated  56  cases  of  early  rupture  of  the  tube  by  the 
expectant  treatment  and  operated  in  63  additional  cases.  Those  treated 


MORTALITY  OF  EXTRA-UTERINE  PREGNANCY  173 

expectantly  were  dismissed  on  an  average  of  fourteen  days  earlier  than 
were  those  on  whom  a  laparotomy  was  performed. 

It  must  be  borne  in  mind  that  the  depression  in  these  cases  was  not 
as  great  as  it  was  in  those  on  whom  laparotomies  were  performed,  and 
hence  the  period  of  convalescence  would  naturally  not  be  so  long. 
It  must  also  be  borne  in  mind  that  Scanzoni  has  not  taken  into  account 
the  disabilities  that  accrue  from  unremoved  pelvic  hematomas,  meaning 
by  them  principally  the  adhesions  which  commonly  develop  in  and 
about  the  site  of  a  hematoma. 

Prochownick  argues  for  early  operative  interference  in  all  of  these 
cases.  He  affirms  that  the  majority  of  his  cases  treated  on  the  expectant 
plan  kept  on  ailing,  whereas  those  on  whom  an  abdominal  or  vaginal 
section  was  performed  gave  better  remote  results.  In  50  laparotomies 
41  gave  good  results  and  in  18  vaginal  incisions  12  made  good  recoveries. 

The  following  statistics  speak  for  the  good  results  in  operated  cases 
of  ruptured  tubal  pregnancy  with  encapsulated  escaped  blood: 

Schauta 82  cases  with  2  deaths 

Ktistner 72  cases  with  1  death 

Fehling 130  cases  with  3  deaths 

Kronig 63  cases  with  0  death 

Total 347  6 

Formad,  formerly  coroner's  physician  in  Philadelphia,  found  hemor- 
rhage due  to  ruptured  tubal  pregnancy  the  cause  of  death  35  times  in 
3500  autopsies. 


CHAPTER    X 


CHORIOEPITHELIOMA  MALIGNUM 


Etiology 

Clinical  Diagnosis 
Macroscopic  Appearance 
Microscopic  Appearance 
Malignant  Degeneration  of  Hyda- 
TiFORM  Mole 


Primary    Chorioepithelioma    Out- 
side OF  the  Placental  Tissue 

Histogenesis 

Diagnosis 
Treatment 


From  the  fact  that  the  histogenesis  of  this  newgrowth  has,  until 
recently,  been  little  understood,  a  number  of  names  have  been  assigned 
to  it.  It  was  called  deciduoma  malignum,  because  it  was  believed  to 
be  a  malignant  proliferation  of  the  decidua.  Sarcomachoriocellulare 
was  a  name  suggested,  on  the  theory  that  the  essential  cell  structures 
were  of  mesoblastic  origin.  On  the  other  hand,  the  name  carcinoma 
syncytiale  was  proposed,  because  of  the  supposed  epithelial  character 
of  the  growth .  The  term  chorioepithelioma  malignum  more  accurately 
expresses  the  true  histogenesis  of  the  growth,  for  it  is  now  generally 
conceded  that  the  growth  is  derived  from  the  epithelial  elements  of 
the  chorion  and  not  from  the  decidua.     (See  Plate  XII.) 

This  tumor  formation  was  first  described  by  Sanger,  in  1888,  before 
the  Obstetrical  Society  of  Leipzig.  Sanger  believed  the  growth  to  be 
a  malignant  proliferation  of  the  decidua,  and  classified  it  as  a  sarcoma. 
L.  Fraenkel  was  first  to  demonstrate  the  origin  of  the  growth  in  the 
epithelium  of  the  chorion.  He  classified  the  tumor  as  a  carcinoma. 
The  present  knowledge  of  the  histogenesis  and  histology  of  chorio- 
epithelioma malignum  is  largely  due  to  Marchand's  important  work  on 
this  subject.  He  demonstrated  that  both  the  syncytium  and  Langhans' 
cells  take  part  in  the  formation  of  the  newgrowth,  and  hence  the  fetal 
origin  of  the  tumor,  though  occupying  maternal  tissues. 

Peters  demonstrated  the  true  genesis  of  the  epithelial  layers  of  the 
chorion,  Langhans'  layer,  and  syncytium  in  his  observations  on  an 
ovum  estimated  to  be  five  to  six  days  old.'  He  has  demonstrated  to 
the  satisfaction  of  most  observers  that  both  the  syncytium  and  Lang- 
hans' layers  are  derived  from  the  ectoderm  or  trophoblast  and  that 
they  are  histogenetically  identical.  Holding  to  this  view  of  the  his- 
togenesis of  Langhans'  layer  and  the  syncytium  a  more  intelligent 
discussion  of  the  histology  of  the  growth  is  possible. 

Etiology.— In  the  author's  analysis  of  210  cases  of  hydatiform  mole, 
he  found  that  16  per  cent,  became  malignant.  It  is  stated  that  from 
40  to  53  per  cent,  of  chorioepithelioma  malignum  cases  follow  the 
expulsion  of  a  hydatiform  mole,  25  to  35  per  cent,  follow  upon  abortions, 
and  20  to  25  per  cent,  follow  upon  full-term  labors.    Briguel  collected 


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ETIOLOGY  175 

181  cases  of  syncytioma  malignum,  in  which  46  were  preceded  by 
normal  labors,  55  by  abortion,  76  by  hydatid  mole,  and  4  by  tubal 
pregnancy.  Tubal  pregnancy  has  given  rise  to  chorioepithelioma 
malignum  in  13  reported  cases.  All  were  fatal  save  the  one  reported 
by  Albert.  It  is  seen  that  hydatid  mole  is  particularly  likely  to  undergo 
malignant  degeneration.  The  time  a  hydatiform  mole  remains  in  utero 
has  no  influence  upon  the  development  of  a  malignant  growth;  there 
is  the  same  liability  to  malignant  transformation  in  the  early  as  in 
the  later  moles. 

In  124  cases  collected  by  Ladinski  the  average  age  of  the  patients 
was  thirty-two  years — the  extreme  ages  seventeen  and  fifty-five  years. 
The  greatest  number  occurred  between  twenty-seven  and  thirty-three 
years  of  age.  In  90  cases  collected  by  the  same  author  the  average 
number  of  children  born  was  4.2.  The  time  of  the  development  of  the 
growth  in  the  placental  site  in  relation  to  the  expulsion  of  a  hydatid 
mole,  an  abortion,  or  a  full-term  labor  is  two  weeks  to  four  and  a  half 
years. 

Clinical  Diagnosis. — The  diagnosis  must  be  based  upon  both  clinical 
and  histological  investigations.  There  is  almost  invariably  a  history 
of  pregnancy  and  the  expulsion  of  a  hydatiform  mole,  an  undeveloped 
fetus,  or  a  full-term  fetus,  weeks,  months,  and  even  years  before  the 
appearance  of  a  malignant  growth. 

The  earliest  symptom  is  hemorrhage.  The  loss  of  blood  increases 
in  amount  and  frequency,  and  very  early  causes  profound  anemia. 
The  usual  means  employed  to  check  hemorrhage  fail  utterly,  and 
may  increase  the  flow.  Persistent  hemorrhage  following  upon  an 
abortion  or  hydatid  mole  is  suggestive  of  syncytioma.  In  curettage, 
the  procedure  must  sometimes  be  abandoned  because  of  the  alarming 
hemorrhage. 

A  dirty,  watery  discharge  occurs,  together  with  and  in  the  intervals 
between  hemorrhages.     Later  this  discharge  assumes  a  foul  odor. 

Pain  is  not  a  notable  symptom.  When  present  it  is  usually  referred 
to  the  thighs  and  sacral  region. 

Cachexia  is  an  early  development,  following  closely  upon  anemia. 
Loss  of  weight  and  strength  is  extreme. 

Symptoms  referable  to  metastasis  are  early  present — so  early  as  to 
be  characteristic  of  the  disease.  In  order  of  frequency  metastatic 
growths  are  found  in  the  lungs,  vagina,  liver,  spleen,  kidneys,  ovaries, 
intestines,  brain,  broad  ligament,  pleura,  lymphatic  glands,  pancreas, 
heart,  stomach,  and  lymph  glands  of  the  pelvis.  It  is  unusual  for  the 
metastatic  growths  to  spread  by  way  of  the  lymph  glands,  as  is  com- 
mon with  carcinoma.  The  cellular  elements  are,  as  a  rule,  conveyed 
by  the  blood  stream,  and  in  this  respect  behave  like  a  sarcoma. 

Fever  of  a  low  grade  is  commonly  present,  and  may  reach  104°  F. 
The  pulse  is  correspondingly  rapid  and  feeble. 

These  clinical  signs  are  very  significant,  but  alone  they  are  not 
sufficient.  The  macroscopic  and  microscopic  features  of  the  growth 
must  be  considered  before  a  diagnosis  can  be  made  with  certainty. 


176  CHORIOEPITHELIOMA   MALIGNUM 

Macroscopic  Appearance. — The  macroscopic  appearances  of  the 
growth  are  generally  characteristic.  The  uterus  is  almost  always 
enlarged,  and  is  commonly  described  as  soft.  In  advanced  cases  there 
may  be  irregularities  on  the  outer  surface  as  well  as  on  the  inner.  The 
cervix  is  usually  patulous  to  the  index  finger,  and  in  the  cavity  of  the 
uterus  may  be  felt  a  soft,  brain-like  mass,  friable,  and  bleeding  profusely 
when  handled.  To  the  naked  eye  this  soft  mass  resembles  at  times 
placental  tissue,  and  at  other  times  a  vascular  sarcoma.  The  color 
of  the  growth  is  mottled  red,  varying  from  a  bright  to  a  dark  shade. 
Necrosis  early  develops.  The  primary  growth  is  not  always  confined 
to  the  uterus.  Cases  have  been  recorded  in  which  the  uterus  remained 
free  and  a  chorioepithelioma  malignum  developed  in  the  vagina,  lung, 
kidney,  liver,  brain,  and  spleen.    (Vide  infra.) 

Microscopic  Appearance. — The  microscope  is  indispensable  in  deter- 
mining the  true  character  of  the  growth.  Under  the  microscope  a 
rapidly  proliferating  structure  is  recognized.  It  is  composed  of  syn- 
cytium and  Langhans'  cells,  which  invade  the  uterine  tissue  in  a  most 
typical  manner,  and  are  early  conveyed  to  distant  portions  of  the  body 
by  way  of  the  blood-stream. 

After  the  expulsion  of  a  hydatid  mole  the  uterus  should  be  explored 
by  the  finger  to  detect  and  remove  any  retained  placental  tissue.  Two 
weeks  later  the  uterus  should  be  curetted  and  the  scrapings  examined 
microscopically.  If  Langhans'  cells  and  the  syncytium  are  found  to 
be  proliferating  in  the  decidua,  the  uterus  should  be  removed  without 
delay.  In  every  abortion  or  full-time  labor,  when  an  unaccountable 
hemorrhage  follows  weeks  and  months  afterward,  an  exploratory 
curettage  should  be  done,  in  view  of  the  possible  finding  of  malignant 
placental  tissue. 

The  microscopic  picture  is  that  of  strands  of  protoplasmic  masses, 
with  nuclei  and  vacuoles  forming  a  reticular  structure.  Polynuclear 
giant  cells  of  syncytium  are  found  in  the  network. 

The  histological  character  of  these  growths  differs  widely.  Two 
chief  classes  are  recognized  by  Marchand:  The  typical  and  atypical. 

Typical  Form. — ^The  typical  form  assumes  the  character  of  the 
chorionic  epithelium  in  the  early  placenta,  in  that  it  presents  a  prolific 
growth  of  syncytium  in  a  more  or  less  established  manner,  together 
with  a  rather  definite  proportion  of  Langhans'  cells.  Not  only  may  the 
epithelial  elements  be  present  in  fairly  definite  proportions,  but  the 
entire  villus,  composed  as  it  is  of  stroma  and  overlying  epithelium, 
may  be  found  in  the  tumor  growth.  In  short,  there  are  found  in  the 
chorioepitheliomatous  growths  all  the  elements  of  the  placenta  which 
are  found  in  the  early  stages  of  pregnancy,  and  the  arrangement  of 
these  elements  is  not  unlike  that  of  the  normal  placenta. 

Atypical  Form. — The  atypical  form  presents  a  remarkable  variation 
in  its  cellular  structure  and  in  the  arrangement  of  its  cells.  The  gen- 
eral arrangement  of  the  elements  in  the  normal  placenta  is  lacking. 
The  shapes  of  the  individual  cells  alone  suggest  placental  tissue,  and 
in  this  there  are  great  variations.   Some  have  been  composed  wholly  of 


MALIGNANT  DEGENERATION  OF  HYDATIFORM  MOLE      177 

syncytium,  others  wholly  of  Langhans'  cells.  There  is  such  variation 
in  structure  that  at  times  it  is  impossible  to  distinguish  Langhans' 
cells  from  syncytium. 

A  feature  worthy  of  special  remark  is  the  large  quantity  of  blood 
in  the  primary  and  secondary  growths.  The  blood  lies  between  the 
cell  elements  and  bathes  them  as  in  the  case  of  the  normal  placenta, 
only  here  an  exaggerated  condition  is  found.  A  further  analogy  between 
the  chorioepitheliomatous  growths  and  the  normal  placenta  is  the 
peculiar  relation  between  the  epithelial  cells  and  blood  fibrin.  In  both 
conditions  fibrin  layers  are  found  between  individual  cells  and  groups 
of  cells.  The  syncytial  cells  penetrate  vessel  walls,  blood  is  liberated, 
and,  as  a  consequence,  thrombi  are  formed  in  the  bloodvessels,  and 
there  is  a  hemorrhagic  infiltration  of  surrounding  tissues  with  the 
formation  of  fibrin.  Fresh  hemorrhages  add  to  the  mass  by  extending 
the  blood-spaces,  and  in  this  manner  the  rapid  growth  of  the  tumor  is 
explained.    The  metastatic  growths  resemble  the  primary  tumor. 

Fig.  79 


,.r"^-idi 


&._  "•;.<?C. 


\^t 


Cystic  degeneration  of  the  ^-illas,  with  an  islet  of  syncytium  within  the  degenerated  stroma. 

Malignant  Degeneration  of  Hydatifonn  Mole. — The  greatest  interest 
in  hydatiform  moles  centres  in  the  fact  that  they  are  likely  to  undergo 
malignant  degeneration.  Solowij  and  Korzysz-Kowski  have  shown 
that  about  10  per  cent,  of  hydatiform  moles  become  malignant.  On 
the  other  hand  it  is  generally  recognized  that  fully  40  per  cent,  of  the 
cases  of  syncytioma  malignum  arise  from  hydatiform  mole.  In  collect- 
ing reported  cases  of  hydatiform  mole  the  author  found  a  scarcity  of 
case  reports  of  non-complicated  hydatiform  mole,  and  that  cases  are 
seldom  reported  unless  they  have  undergone  malignant  degeneration. 
For  this  reason  it  is  impossible  to  arrive  at  any  exact  estimate  of  the 
frequency  of  hydatiform  moles  and  of  their  malignant  degeneration. 
According  to  the  reported  cases,  which  include  all  the  author  was  able 
to  find  in  the  literature,  it  appears  that  16  per  cent,  of  hydatiform  moles 
become  malignant.    It  is  probable  that  this  percentage  is  far  too  high. 

From  the  very  onset  the  difficulties  involved  in  dealing  with  the 
many  mooted  questions  concerning  the  malignancy  of  hydatiform 
12 


178  CHORIOEPITHELIOMA  MALIGNUM 

mole  appear  insurmountable.  The  intimate  blending  of  fetal  and 
maternal  structures,  together  with  the  secondary  processes  of  degen- 
eration, are  so  complicated  and  so  subject  to  variations  that  it  is 
difficult  and  at  times  impossible  to  distinguish  the  benign  from  the 
malignant.  Indeed,  ^'an  der  Hoeven  goes  so  far  as  to  state  that  all 
hydatiform  moles  are  malignant;  that  the  proliferation  of  the  epithelial 
elements  of  the  chorion  (syncytium,  Langhans)  assumes  a  malignant 
type  in  the  invasion  of  the  uterine  musculature  and  connective-tissue 
stroma  of  the  villi.  He  further  reasons  that  if  this  tendency  on  the  part 
of  the  epithelial  elements  to  proliferate  is  not  marked,  or  if  the  mole 
is  expelled  or  removed  before  the  epithelium  invades  the  uterine  tissue 
beneath  the  line  of  cleavage  (within  the  compact  layer  of  the  decidua), 
there  can  be  no  recurrence.  If  left  behind  in  the  uterine  tissue,  the 
epithelial  elements  continue  to  proliferate  and  to  be  carried  to  distant 
parts  of  the  body  by  way  of  the  blood  stream,  there  forming  metastatic 
malignant  epithelial  growths. 

Fig.  so 


Beginning  degeneration  of  the  stroma,  with  unusual  proliferation  of  the  SJ-nc^■tium. 

Neumann  studied  8  cases  of  hydatiform  mole;  5  were  not  followed 
by  malignant  changes,  3  died  of  syncytioma  malignum.  In  the  5 
so-called  benign  moles  the  epithelium  of  the  chorion  proliferated  to  an 
unusual  degree,  but  did  not  invade  the  connective  tissue  of  the  stroma, 
while  in  the  3  malignant  moles  the  connective-tissue  stroma  was 
invaded  by  syncytial  giant  cells.  Neumann  arrived  at  the  conclusion 
that  the  earliest  evidence  of  malignancy  lay  in  the  invasion  of  the 
connective-tissue  stroma  of  the  villi  by  the  epithelial  elements  of  the 
chorion.  As  suggested  by  Pierce,  the  "view  of  Neumann  is  not  gen- 
erally recognized,  and  with  right,  for  cases  of  nephritis  and  lead  poison- 
ing have  since  been  described  in  which  the  same  cells  were  found  in  the 
stroma  of  normal  villi;  hence  their  presence  can  have  no  pathological 
significance  in  hydatiform  mole." 
-    It  is  evident  from   the   observations   of  Veit,  Webster,  Pick,  and 


MALIGXAXT  DEGEXERATIOX  OF  HYDATIFORM   MOLE      179 

others,  that  the  mvasion  of  the  deep  structures  of  the  uterus,  and  even 
of  structures  beyond  the  uterus,  by  chorionic  epithehum,  is  not  evidence 
per  se  of  mahgnancy;  that,  on  the  contrary,  syncytial  masses  are  found 
in  the  uterine  musculature,  and  are  deported  to  distant  parts  of  the 
body  by  veins  in  normal  pregnancy;  that  soon  after  the  termination  of 
pregnancy  they  are  no  longer  found.  The  transition  between  benign 
and  malignant  chorioepithelial  elements  is  gradual  and  imperceptible, 
just  as  is  the  transition  of  all  benign  hyperplastic  growths  into  the 
malignant  types.  To  differentiate  them  is  manifestly  impossible.  There 
undoubtedly  exists  an  intermediate  stage  between  the  benign  and 
malignant.  Berry  Hart  examined  a  hydatiform  mole  in  which  the 
epithelial  changes  were  identical  with  those  described  in  the  malignant 
type;  no  recurrence  followed  the  expulsion  of  the  mole.  Both  the 
syncytium  and  Langhans'  cells  participate  in  the  proliferative  changes, 
but  to  a  varying  degree.  There  is,  likewise,  great  variation  in  the 
rate  of  growth  in  the  epithelial  elements,  the  explanation  not  onl}^ 
lying  inherent  within  the  cell  elements,  but  also  in  the  degree  of  resist- 
ance offered  by  the  uterine  tissue. 

Two  of  the  cases  described  by  Ivworostansky  were  in  the  second 
month  of  pregnancy — one  was  a  benign  hydatiform  mole,  the  other  a 
sync^'tioma  malignum.  It  is  of  the  greatest  interest  to  compare  these 
two  cases  from  an  anatomical  point  of  view.  In  the  benign  mole  there 
was  unusual  proliferation  of  the  syncytium  and  Langhans'  layer, 
forming  a  loose  connection  with  the  decidua  serotina;  in  the  veins  of 
the  serotina,  both  sjmcj'tial  and  Langhans'  cells  were  found  in  limited 
numbers.  The  decidua  vera  was  invaded  to  a  lesser  degree;  no  epithelial 
elements  were  found  in  the  uterine  musculature.  In  the  placental 
site  were  evidences  of  endometritis,  as  demonstrated  in  scrapings 
removed  six  weeks  after  the  expulsion  of  the  mole.  The  case  recovered 
without  recurrence.  The  author  states  that  the  patient,  aged  twenty- 
four  years,  was  anemic,  and  that  this  impoverishment  of  the  blood 
afforded  insufficient  nourishment  to  the  villi,  thereby  exciting  the 
chorionic  epithelium  to  extend  deeper  into  the  uterine  musculature  in 
order  to  obtain  greater  nourishment.  Sufficient  ncurishment  not  being 
provided  by  the  stroma  of  the  villi,  necrosis  follows.  In  the  second  case, 
which  was  malignant,  there  was  also  extreme  anemia.  The  epithelial 
elements  behaved  like  those  of  the  first  case,  only  to  an  exaggerated 
degree,  apparently  differing  only  in  the  degree  of  epithelial  invasion 
of  uterine  structures.  The  syncytial  cells  invaded  the  intermuscular 
spaces  and  veins  of  the  uterus  as  far  as  the  parametrium.  Atrophy 
and  necrosis  of  the  decidual  and  muscular  elements  followed;  blood- 
vessels were  changed  to  blood-lacuna?.  In  comparing  my  specimen  of 
benign  hydatiform  mole  with  one  having  undergone  malignant  changes, 
it  was  advisable  to  select  for  comparison  not  only  one  of  similar  age, 
but  also  one  that  had  been  removed  together  with  the  uterus,  as  was 
mine.  In  this  way  certain  retrogressive  changes  and  the  disturbance 
of  anatomical  relations  which  would  otherwise  mislead  can  be  avoided. 
Two  such  cases  have  been  reported — one  by  Boten  and  Vassmer,  the 


180 


CHORIOEPITHELIOMA   MA LIGN UM 


other  b\'  Xeumann.  In  both  these  cases  the  essential  variations  from 
my  own  case  appear  to  lie  in  the  more  marked  proliferation  of  the 
syncytium  and  Langhans'  cells  and  in  their  extended  invasion  of  the 
uterine  veins  and  musculatiu-e.  AMiile  it  is  not  to  be  expected  that  a 
benign  mole  may  be  distinguished  from  a  malignant  mole  by  the  naked 
eye,  yet  it  is  worth  while  to  observe  that  Pautz  and  others  have  found 
in  malignant  moles  that  the  villi  rarely  attain  large  size,  are  firm,  and 
have  a  long,  slender  pedicle,  giving  to  the  mole  the  appearance  of  soft- 
cooked  rice. 

Fig.  81 


Showing  sjTicytial  invasion  of  the  stroma. 

Ladinski,  in  a  clinical  review  of  deciduoma  malignum,  reported 
a  case  of  hydatiform  mole  followed  by  malignant  degeneration.  He 
collected  thirty-three  similar  cases,  and  concluded  that  malignant 
degeneration  occurred  most  frequently  in  cases  in  which  mole  pregnancy 
terminated  in  the  fourth  month.  It  does  not  appear  that  the  length 
of  time  a  mole  remains  in  utero  has  any  influence  upon  its  disposition 
to  become  malignant.  In  twenty  cases  Ladinski  finds  the  average  time 
of  appearance  of  s^mcytioma  malignum  is  eight  weeks  after  the  mole 
has  been  expelled. 

An  early  diagnosis  of  hydatiform  mole  is  of  importance  because  of 
the  liability  to  malignant  degeneration.  While,  as  a  rule,  there  will 
be  the  usual  clinical  signs  of  a  mole  some  time  before  malignant  changes 
develop,  there  is  always  the  possibility  of  early  malignant  transforma- 
tion, and  it  is  not  possible  to  detect  these  early  malignant  changes. 

The  only  safeguard  lies  in  the  early  recognition  of  the  mole  and 
in  its  immediate  removal. 


MALIGNANT  DEGENERATION  OF  HYDATIFORM  MOLE     181 

Will  the  microscope  supply  an  infallible  means  of  making  an  early 
diagnosis  of  malignant  degeneration  of  a  molef  Van  der  Hoeven  and 
Neumann's  statements  that  epithelial  invasion  of  the  stroma  of  the 
villi  is  the  earliest  and  at  all  times  reliable  evidence  of  malignancy 
cannot  be  accepted.  Such  findings  are  not  uncommon  in  normal 
pregnancy.  Marchand  failed  to  find  the  stroma  invaded  in  a  malignant 
mole,  and  Ruge  found  such  invasion  in  an  undoubted  benign  mole.  In 
my  second  case  there  was  epithelial  invasion  of  the  stroma  of  the  villi. 
Ten  years  have  elapsed  since  the  removal  of  the  mole,  and  no  signs  of 
malignancy  have  developed. 

In  a  case  reported  by  Poten  the  mole  went  on  to  the  time  of  full- 
term  pregnancy.  Neumann's  cells  were  found  in  the  stroma  of  the 
villi.  On  the  twenty-sixth  day  after  the  mole  was  expelled,  hemorrhage 
recurred  to  a  slight  degree.    The  uterus  was  curetted,  and  a  microscopic 

Fig.  82 


Giant  syncytial  cells  showing  vacuoles. 

examination  of  the  scrapings  showed  no  evidence  of  malignant  invasion; 
recovery  followed.  This  case  shows  how  difficult,  and  at  times  impos- 
sible, it  is  to  determine  the  character  of  a  hydatiform  mole.  In  the 
light  of  present  knowledge  a  guarded  diagnosis  must  ahvays  be  made 
in  the  early  stage;  and  at  no  time  can  a  diagnosis  be  made  2vith  absolute 
certainty  from  the  appearance  of  the  expelled  mole.  The  invaded  decidua, 
and  if  possible  the  underlying  musculature,  will  alone  afford  evidences 
of  malignant  invasion  prior  to  the  development  of  metastasis.  In  the 
case  reported  by  Schmidt  a  diagnosis  of  malignancy  was  first  made 
from  a  microscopic  examination  of  a  metastatic  growth  which  appeared 
in  the  vagina.  The  uterus  was  not  removed,  and  recovery  followed 
the  removal  of  the  vaginal  growth.  When  hemorrhage  recurs  days 
or  weeks  after  complete  removal  of  the  mole,  the  uterus  should  be 
curetted  and  the  scrapings  examined  for  active  and  extensive  invasion 


182  CHORIOEPITHELIOMA   MA  LIGNUM 

of  the  uterine  tissues.  Large  nuclei,  rich  in  chromatin  and  mitotic 
figures,  together  witli  a  tendency  on  the  part  of  the  protoplasm  to 
separate  into  individual  cells  or  chains  of  cells,  are,  according  to  Voigt 
and  Gottschalk,  suggestive  of  malignancy. 

There  is  as  yet  no  certain  means  of  making  an  absolute  and  early 
diagnosis  of  malignant  degeneration  of  a  hydatiform  mole.  The  clinical 
signs,  together  with  the  gross  and  microscopic  appearances,  are  all 
to  be  carefully  considered.  In  view  of  the  inability  to  make  an  absolute 
early  diagnosis,  vesicular  degeneration  of  the  chorion,  however  limited, 
demands  immediate  interference,  to  be  followed  by  a  period  of  at 
least  tliree  years  of  watchful  expectancy.  If  at  any  time  following  the 
expulsion  of  the  mole,  hemorrhage  recurs,  the  uterus  should  be  curetted 
and  a  microscopic  examination  made  of  the  scrapings. 

Prognosis. — ^Experience  teaches  that  all  cases  must  be  looked  upon 
with  suspicion  even  months  and  years  after  the  removal  of  the  mole. 
It  is  seldom  that  serious  consequences  occur  while  the  mole  is  in  utero. 
^Malignant  degeneration,  rupture  of  the  uterus,  fatal  hemorrhage— 
aU  these  have  occurred  with  the  mole  in  situ,  though  such  happenings 
are,  fortunately,  rare.  Remote  results,  i.  e.,  a  repetition  in  subse- 
quent pregnancies  and  malignant  degeneration  of  retained  chorionic 
epithelium,  are  to  be  feared.  Heitzman  estimated  the  mortality  at 
13  per  cent.  These  statistics  were  gathered  at  a  time  when  chorioepi- 
thelioma  malignum  was  not  recognized.  It  is  generally  accepted  that 
10  per  cent,  of  hydatiform  moles  undergo  malignant  degeneration, 
and  this  estimate  also  approximately  expresses  the  death-rate  of 
hydatiform  mole;  but  it  is  far  too  small,  as  shown  by  the  following 
data.  Deaths  from  hemorrhage  and,  to  a  lesser  degree,  from  septic 
infection  and  rupture  of  the  uterus  add  materially  to  the  death  rate, 
bringing  the  mortality  to  near  25  per  cent. 

In  the  author's  210  cases  collected  from  the  literature  there  were 
49  deaths — a  mortality  of  about  25  per  cent.  Of  this  number  32  died 
from  syncytioma  malignum  (16  per  cent.);  7  died  from  hemorrhage 
(4  per  cent.) ;  4  died  from  septic  peritonitis  (2  per  cent.) ;  1  died  from 
general  sepsis;  1  from  uremia;  1  from  endocarditis  and  nephritis;  1 
from  meningitis,  and  2  from  unknown  causes.  The  author  does  not 
regard  these  statistics  as  expressing  actual  facts.  There  is  doubtless 
a  tendency  to  report  all  cases  resulting  fatally  and  to  overlook  those 
having  no  special  point  of  interest  in  their  course  and  termination. 

The  later  in  pregnancy  we  have  to  do  with  vesicular  degeneration 
of  the  chorion  the  more  grave  the  prognosis,  because  of  the  difficulty 
in  removing  the  mole  and  the  greater  likelihood  of  rupture  of  the 
uterus  and  of  malignant  degeneration.  It  has  been  stated,  and  will 
bear  repetition,  that  the  removal  of  a  hydatiform  mole  is  imperative 
as  soon  as  the  diagnosis  is  established.  There  can  be  no  temporizing, 
however  limited  the  vesicular  degeneration  and  however  early  or  late 
the  condition  is  recognized. 

Primary  Chorioepithelioma  Malignum  Outside  of  the  Placental  Site. 
—In  the  21  cases  collected  by  the  author  unmistakable  chorioepithe- 


PRIMARY  CHORIOEPITHELIOMA   M ALIGN UM  183 

liomatous  tumors  have  been  observed  in  locations  remote  from  the 
placental  site  of  the  uterus  and  Fallopian  tubes.  In  no  case  has  it 
been  possible  to  trace  a  direct  anatomical  connection  between  the 
placental  site  and  the  primary  tumor. 

In  nearly  all  cases  it  has  been  possible  to  trace  a  direct  clinical  relation 
between  pregnancy  and  the  tumor  formation.  These  tumors  have 
arisen  during  the  course  of  pregnancy,  at  varying  intervals  after  the 
completion  of  normal  pregnancy,  following  complete  and  incomplete 
abortions,  while  hydatiform  moles  were  in  situ  and  at  variable  times 
after  their  expulsion.  In  no  instance  has  such  a  growth  been  recognized 
in  a  nullipara,  though  in  one  instance  the  appearance  of  the  tumor 
followed  the  establishment  of  the  menopause. 

In  primary  chorioepithelioma  of  the  placental  site  the  vagina  is 
most  often  the  seat  of  secondary  invasion  by  metastasis.  It  is  also 
true  that  primary  extra-uterine  chorioepithelioma  arises  with  greatest 
frequency  in  the  vaginal  walls.  This  is  an  exception  to  the  rule  that 
tissues  which  are  a  common  seat  of  primary  malignant  growths  are 
seldom  a  seat  of  secondary  invasion  by  these  growths.  The  following 
presents  the  topographical  distribution  of  the  chorioepitheliomata 
in  regions  not  connected  with  the  placental  site:  vagina,  14;  lungs,  8; 
liver,  5;  brain,  5;  kidney,  5;  uterine  musculature,  3;  intestine,  3,  and 
1  each  in  spleen,  thyroid,  suprarenal  gland,  retroperitoneal  lymph  gland, 
heart  muscle,  ovary,  bladder,  labium,  and  mediastinum. 

It  was  not  always  possible  to  identify  the  primary  growth  apart 
from  the  secondary  metastatic  growths.  The  vagina  was  believed 
to  be  the  primary  seat  in  11  cases;  the  uterine  musculature  in  3  cases; 
the  cervix,  brain,  kidney,  and  labium  each  in  1  case.  In  the  remaining 
3  cases  it  was  not  possible  to  identify  the  primary  growths.  The  size 
was  not  found  to  be  a  safe  guide  in  judging  the  priority  of  the  growth. 
For  example,  in  the  case  reported  by  Fiedler  the  primary  growth  in 
the  uterine  musculature  was  the  size  of  a  cherry-stone,  while  in  the 
liver  there  was  a  secondary  growth  the  size  of  a  child's  head. 

Undoubtedly  small  metastatic  growths  in  various  portions  of  the 
body  are  frequently  overlooked,  and  subsequently  disappear  spon- 
taneously. They  are  known  to  vary  in  size  from  that  of  a  hazelnut 
to  a  child's  head,  and  in  number  from  one  to  a  score  or  more.  Multiple 
growths  in  the  same  organ  or  tissue  have  been  repeatedly  described, 
and  in  all  cases  there  was  an  almost  uniform  appearance  in  the  gross 
structure.  In  general,  they  have  presented  the  macroscopic  appearance 
of  blood-clots.  As  a  rule  they  were  of  firm  consistency,  bluish  red  in 
color,  and  on  cross-section  presented  a  fibrinous-like  character  in  the 
centre  of  the  blood-coagulum. 

In  the  vagina  the  overlying  mucosa  was  frequently  ulcerated,  and 
through  the  defective  covering  blood  escaped.  Occasionally  the  hem- 
orrhage was  so  great  as  to  require  tamponing  or  immediate  operation. 

In  all  cases  of  primary  vaginal  growths  the  hemorrhage  was  at 
first  thought  to  come  from  the  uterus,  but  direct  inspection  readily 
located  the  seat  of  hemorrhage  in  the  vaginal  tumor,  and  a  subsequent 


184  CHORIOEPITHELIOMA  MALIGNUM 

exploratory  curettage,  with  microscopic  examination  of  scrapings, 
excluded  the  presence  of  the  growth  in  the  uterus. 

Histogenesis. — It  is  interesting  to  speculate  on  the  genesis  of  these 
growths.  Was  the  placental  tissue  malignant  when  in  utero,  and  had 
metastatic  invasion  been  instituted  prior  to  a  complete  expulsion  of 
the  malignant  placental  tissue  from  the  uterus?  Is  it  possible  to 
conceive  of  a  complete  spontaneous  expulsion  of  malignant  placental 
tissue  from  the  uterus — i.  e.,  self-elimination  of  the  original  uterine 
tumor  while  the  metastatic  growths  remain  in  distant  portions  of  the 
body  and  continue  to  develop  ?  Is  spontaneous  involution  of  the  original 
uterine  tumor  possible  ?  Is  it  possible  that  the  primary  growth  at  the 
placental  site  was  removed  by  the  curet  or  finger?  These  are  interest- 
ing and  important  questions,  which  future  investigation  must  answer. 

It  has  been  shown  conclusively  by  Webster,  Veit,  Pick,  and  later 
observers  that  not  only  chorionic  epithelium,  but  the  entire  villus  as 
well  is  carried  to  distant  parts  of  the  body  through  the  blood-stream, 
and  this  under  perfectly  normal  conditions. 

May  these  deported  elements  proliferate  to  form  tumor  growths 
which  may  be  benign  in  one  case,  malignant  in  another,  and  leave  the 
uterus  free  from  tumor  formation? 

With  our  present  knowledge  of  the  placenta  these  problems  cannot 
be  solved.  Macroscopic  and  microscopic  examinations  of  the  expelled 
placenta  of  hydatiform  mole  and  of  scrapings  from  the  placental  site 
afford  no  information,  because  it  is  impossible  to  distinquish  a  malig- 
nant from  a  benign  growth  of  the  epithelial  elements  found  in  these 
structures. 

Neumann's  statement  that  malignancy  is  recognized  by  the  epithelial 
invasion  of  the  stroma  of  the  villus  has  been  disproved. 

The  atypical  growth  of  syncytium  with  large  and  richly  chromatic 
nuclei  has  been  regarded  by  Gottschalk  and  others  as  indicative  of 
malignancy;  but  this,  too,  has  been  disproved. 

The  proliferation  of  Langhans'  cells  and  their  atypical  distribu- 
tion were  thought  by  Voight  to  suggest  malignancy,  but  subsequent 
investigations  fail  to  substantiate  his  views. 

Primary  chorioepitheliomatous  growths  outside  of  the  placental  site 
have  developed  where  macroscopic  examinations  of  the  expelled  mole 
or  placenta  showed  none  of  these  features  (Pick,  Guerard). 

The  fact  that  syncytium  under  normal  conditions  is  known  to 
disappear  spontaneously  from  uterine  and  other  tissues  leaves  the 
question  open  as  to  the  possibility  of  malignant  chorioepithelioma 
spontaneously  disappearing  from  the  uterus. 

Under  perfectly  normal  conditions  the  syncytium  proliferates 
rapidly,  destroying  tissues  as  it  advances,  burrowing  into  bloodvessels, 
and  is  carried  to  distant  portions  of  the  body.  So  far  as  it  is  at  present 
possible  to  judge,  the  difference  in  the  behavior  of  normal  syncytium 
and  the  malignant  type  is  one  of  degree  in  its  proliferating  tendencies. 
It  is  probable,  as  Risel  has  suggested,  that  the  difference  between  the 
benign  and  the  malignant  syncytial  growth  does  not  lie  in  these  elements, 


PRIMARY  CHORIOEPITHELIOMA  M ALIGN UM  185 

but  is  dependent  upon  the  peculiar  resistance  of  the  tissues  invaded. 
Every  possible  gradation  is  found  between  the  normal  placenta,  the 
hydatiform  mole,  and  chorioepithelioma  malignum,  and  a  transition 
from  one  to  the  other  in  the  order  named  is  possible. 

Permanent  healing  has  followed  the  removal  of  the  growths,  and 
even  the  partial  removal,  as  in  the  case  of  Fleischmann,  in  which  a 
secondary  vaginal  tumor  was  removed,  together  with  only  a  portion 
of  the  primary  uterine  tumor.  Not  only  did  the  uterine  tumor  com- 
pletely disappear,  but  there  was  subsequent  childbearing  and  complete 
recovery. 

The  microscopic  examination  of  the  tissues  scraped  from  the  uterus 
showed  what  appeared  to  be  a  typical  chorioepithelioma  malignum. 

The  only  conclusion  to  be  drawn  is  that  there  is  no  way  of  judging 
the  malignancy  of  these  growths  save  by  the  subsequent  course  of  the 
case. 

Schlagenhaufer  and,  at  about  the  same  time,  but  independently, 
\Vlassow  observed  chorioepitheliomatous  growths  in  the  testicle 
identical  to  those  found  in  the  female.  These  growths  are  regarded 
by  the  observers  to  have  the  same  histogenesis — i.  e.,  they  arise 
from  embryonic  elements  of  the  fetal  ectoderm  and  contain  both 
syncytium  and  Langhans'  cells.  Wlassow  examined  twelve  teratomata 
of  the  testicles  and  found  this  peculiar  cell  structure  in  three.  L.  Pick 
has  since  found  a  similar  structure  in  ovarian  tissue.  Risel,  Schmorl, 
and  Steinhaus  have  made  further  observations  in  cases  of  chorioepi- 
thelioma malignum  of  the  testicle.  It  is  possible,  though  not  yet 
proved,  that  such  tumors  may  occur  elsewhere  in  the  male.  Breus 
(1878)  recorded  a  testicular  tumor,  with  a  secondary  tumor  in  the 
heart,  which  Schlagenhaufer  regarded  as  a  malignant  hydatiform  mole 
in  the  male,  and  Breus  later  accepted  his  views  as  higlily  probable. 

It  is  probable  that  in  the  antenatal  period,  when  the  fetus  is  little 
more  than  a  segmentation  sphere,  one  or  more  polar  bodies  or  blasto- 
meres  become  displaced  and  incorporated  in  the  structures  which  go 
to  make  the  testicle,  and  later  develop  into  structures  comprising  all 
three  layers  of  the  blastoderm. 

Why  a  complete  embryo  is  not  develoj>ed  and  why  the  growth  at 
times  becomes  malignant  are  unsolved  problems. 

Diagnosis. — From  a  study  of  reported  cases  it  is  observed  that  the 
clinical  diagnosis  of  primary  chorioepithelioma  has  only  been  made  in 
the  cases  in  which  the  lesion  could  be  directly  inspected — i.  e.,  in  the 
vagina,  labium,  and  cervix.  They  were  recognized  by  their  character- 
istic rounded  shape  and  bluish  color,  their  tendency  to  bleed  freely, 
and  by  the  absence  of  uterine  hemorrhage,  together  with  negative 
findings  in  the  uterus,  after  exploring  with  the  finger  and  curet. 

The  clinical  diagnosis  was  at  all  times  confirmed  by  microscopic 
examinations  of  portions  of  excised  or  curetted  tissue.  Without  the 
microscope  a  positive  diagnosis  is  not  possible. 

Tumors  lying  in  hidden  portions  of  the  body — e.  g.,  kidney,  liver, 


186  CHORIOEPITHELIOMA  M ALIGN UM 

and  lung — were  not  diagnosticated  with  certainty  without  a  post- 
mortem examination. 

When  the  case  did  not  end  fatally  it  was  not  possible  to  say  that 
the  growth  was  malignant,  from  the  fact  that  the  macroscopic  and 
microscopic  findings  in  these  growths  were  in  no  way  diagnostic  of 
malignancy. 

The  ages  at  time  of  operation  were  twenty  to  fifty  years.  Twelve 
of  the  seventeen  cases  in  which  the  age  was  recorded  occurred  between 
thirty-five  and  forty-one  years  of  age. 

Among  these  there  is  one  case  in  which  a  hydatiform  mole  was  in 
utero  at  the  time  of  the  appearance  of  the  symptoms  and  primary 
growth.  In  another  case  there  was  a  two  months'  fetus  in  utero.  In 
three  cases  the  tumor  followed  incomplete  abortions;  in  three  others 
the  abortions  were  complete,  and  seven  cases  had  had  normal  labors. 

In  all  cases  in  which  there  were  vaginal  or  cervical  tumors,  hemor- 
rhage was  the  symptom  which  led  to  the  detection  of  the  growth. 
In  exceptional  cases  a  foul-smelling  vaginal  discharge  followed  the 
appearance  of  the  hemorrhage. 

From  the  fact  that  these  growths  are  so  frequentl}^  located  in  the 
vagina,  and  that  hemorrhage  is  an  early  and  constant  symptom, 
suspicion  should  always  be  aroused  by  the  occurrence  of  bleeding 
from  the  vagina  during  the  course  of  pregnancy  after  the  expulsion 
of  a  hydatiform  mole,  an  abortion,  or  labor. 

If  on  inspection  such  a  tumor  is  found  it  should  be  excised,  and  if  on 
microscopic  examination  chorionic  epithelium  is  found  an  exploratory 
curettage  of  the  uterus  should  be  made.  The  microscopic  findings  in 
the  scrapings,  however,  cannot  be  depended  upon  in  determining  the 
malignancy;  hence,  because  of  these  present  limitations,  it  would 
appear  to  be  advisable  to  make  a  complete  extirpation  of  the  uterus 
when  syncytial  tissue  is  found  in  the  scrapings.  The  cases  which 
have  recovered  after  the  removal  of  the  vaginal  growth  without  hys- 
terectomy do  not,  as  far  as  present  knowledge  goes,  justify  leaving 
the  uterus  unless,  by  an  exploratory  curettage,  the  uterus  is  found  free 
from  all  chorionic  epithelium. 

The  relation  of  hydatiform  mole  to  chorioepithelioma  malignum 
is  discussed  on  page  177. 

The  diagnosis  of  the  malignant  character  of  a  chorioepithelioma 
cannot  be  based  upon  the  macroscopic  or  microscopic  appearances 
of  the  growth,  nor  will  the  presence  of  metastatic  growths  confirm 
the  diagnosis.  The  histological  and  naked-eye  appearances  are  the 
same  in  the  benign  as  in  the  malignant  forms,  and  metastatic  growths 
have  been  known  to  disappear  spontaneously.  The  ultimate  clinical 
course  must  therefore  be  depended  upon  for  the  diagnosis  of  malignancy. 

Treatment. — The  treatment  consists  in  the  removal  of  the  entire 
uterus  and  its  appendages  at  the  earliest  possible  moment. 

The  high  mortality  in  cases  following  labor  at  term  is  very  striking. 


CHAPTER   XI 
NON-OPERATIVE   :METH0DS   OF  TREATMENT 


Hydrotherapy 
Hot  Air  Treatment 
Hot  Pack 
Counter-irritatiox 
Tampons 
Pelvic  Massage 


Pressure  Therapy 

Electricity 

X-RAY  Therapy 

Swabs 

Serum  and  Organotherapy 


Prior  to  the  days  of  antisepsis  and  asepsis,  operations  were  performed 
for  the  relief  of  only  a  limited  number  of  the  diseases  peculiar  to  women 
and  these  were  practically  confined  to  the  plastic  operations  upon  the 
cervix,  vagina,  and  perineum.  Even  these  operations  did  not  meet 
with  general  favor  because  of  the  dangers  involved  from  hemorrhage 
and  infection,  and  the  small  percentage  of  satisfactory  results. 

At  such  a  time  it  was  but  natural  that  relief  should  be  sought  in 
more  conservative  ways.  Accordingly  the  profession  seriously  dis- 
cussed the  value  of  electricity,  massage,  internal  medication,  etc.,  for 
relief  from  ailments  which  are  now  regarded  as  preeminently  surgical. 
The  explanation  for  these  measures  lay  not  only  in  the  shortcomings 
of  surgery,  but,  in  part,  in  the  lack  of  knowledge  of  the  pathology  of 
intrapelvic  lesions.  As  a  logical  sequence,  diagnosis  and  treatment  had 
no  rational  scientific  basis. 

The  advent  of  antiseptic  surgery  ultimately  made  possible  the  explo- 
ration of  the  pelvic  cavity  with  comparative  safety,  thereby  affording 
abundant  opportunities  for  the  study  of  these  lesions.  An  operative 
furore  was  created,  which  for  a  time  so  possessed  the  profession  that 
non-operative  means  of  relieving  the  ailments  of  women  were  almost 
wholly  lost  sight  of.  Organs  were  sacrified,  partly  in  ignorance,  partly 
for  greed  of  gain. 

Happily,  at  no  time  were  these  extreme  practices  universally  com- 
mended; there  were  always  weighty  voices  raised  to  challenge  the 
practices  of  the  rash,  the  vicious,  and  the  ignorant. 

Having  applied  non-operative  methods  to  all  but  the  exclusion  of 
the  operative,  and  later  the  operative  to  the  nearly  universal  annihila- 
tion of  the  non-operative,  the  profession  has  come  to  the  position  of 
true  conservatism.  The  limitations  of  non-operative  therapy  are  now 
appreciated,  and  it  is  accorded  its  rightful  place  in  the  treatment  of 
diseases  of  w^omen.  Similarly  surgery  now  has  its  limitations;  the  one 
is  not  employed  to  the  exclusion  of  the  other  but,  hand  in  hand,  they 
work  for  good. 

General  and  local  treatments  are  made  to  accomplish  what  siu-gery 


188  NON-OPERATIVE  METHODS  OF  TREATMENT 

has  failed  to  do  in  selected  cases.  ]\Iore  often  they  are  used  as  a  fore- 
runner and  accompaniment  of  surgery,  and  as  a  means  of  obtaining 
a  better  result  subsequent  to  operation. 

The  author  believes  in  the  inestimable  value  of  so-called  local  treat- 
ments, not  only  as  an  aid  to  surgery,  but  also  in  many  instances  as  the 
only  method  required  to  obtain  the  desired  result.  Everything  depends 
upon  the  intelligent  application  of  the  treatments.  As  often  practised 
they  are  of  no  value  and  are  more  meddlesome  than  useful. 

In  order  that  their  full  value  may  be  understood  and  their  limitations 
be  clearly  defined,  the  author  deems  it  necessary  to  present  a  detailed 
description  of  the  technic,  and  a  comprehensive  discussion  of  the 
indications  and  contraindications  for  all  non-operative,  therapeutic 
measures  applied  to  diseases  of  women.  They  are  worthy  of  more 
generous  recognition  than  has  heretofore  been  accorded  to  them  in 
text-books  and  monographs. 

The  physician  who  is  most  successful  in  the  treatment  of  diseases 
peculiar  to  women  will  give  due  consideration  to  all  conditions — 
phj'sical,  social,  and  moral — which  influence  the  life  of  women,  and 
he  must  not  lose  sight  of  the  fact  that  gynecology  is  an  integral  part 
of  the  general  medical  science.  Hence  it  follows  that  the  genital  organs 
of  women  are  not  a  law  unto  themselves,  but  are  subject  to  the  laws 
which  govern  the  body  in  general. 


HYDROTHERAPY 

Baths  Ice-bag 

Vaginal  Douche  '  Hot  Compresses 

Intra-uterine  Douche 
Saline  Injections 

Enteroclysis 

HjT)odermoclysis 

Intravenous 


Hot-water  Bag 
Water  Drinking 


Baruch  says:  "A  somewhat  extensive  experience  has  convinced 
me  that,  although  water  is  a  simple  remedy  and  so  easily  applied  that 
anyone  seems  justified  in  using  it,  I  must  insist,  with  full  consciousness 
of  the  import  of  my  words,  that  no  remedy  in  the  entire  materia  medica 
demands  as  clear  judgment  and  as  much  knowledge  of  the  patient's 
condition  as  does  the  application  of  water." 

The  value  of  water  as  a  remedial  agent  is  not  fully  appreciated, 
because  the  physiological  action  of  water  is  not  generally  understood 
by  the  profession.  Hydrotherapy,  accordingly,  is  not  applied  with  that 
discriminating  sense  which  brings  desired  results.  Water  is  one  of  the 
most  valuable  therapeutic  agents  in  the  treatment  of  diseases  of  women, 
but  the  laws  of  hydrotherapy  must  be  understood  if  they  are  to  be 
applied  successfully.  The  physiological  action  of  water  applied  to  the 
surface  of  the  body  or  to  the  vagina  and  bowel  produces  a  mechanical 


HYDROTHERAPY 


189 


effect  upon  the  tissues  with  which  it  comes  in  contact,  and  upon  the 
nerves  and  vessels  supplying  these  structures. 

The  direct  impact  of  the  water  cleanses  the  surface  or  cavity  and 
stimulates  the  peripheral  vasomotor  nerves,  thereby  producing  a  primary 
effect  of  stimulation  in  proportion  to  the  force  of  impact  and  to  the 
degree  of  heat  or  cold.  If  the  application  is  long  continued  the  effect 
of  stimulation  gives  place  to  that  of  relaxation.  If  the  area  involved 
is  of  considerable  extent  the  general  vascular  system  will  be  influenced 
in  the  same  manner  as  are  the  vessels  in  the  tissues  directly  affected. 
By  stimulating  the  general  circulation,  the  nutrition  and  secretions  of 
the  body  are  influenced;  thus,  a  general  as  well  as  a  local  reaction  is 
obtained  which  contributes  to  the  general  well-being. 


Fig.  83 


A  modern  bath. 


Baths. — By  the  application  of  hot  or  cold  water  to  the  surface  of 
the  body,  both  the  vasomotor  nerves  and  the  muscular  fibers  are 
stimulated.  In  this  respect  cold  produces  the  same  effect  as  heat, 
differing  only  in  degree.  The  degree  of  heat  or  cold  and  the  duration 
of  the  application  determine  the  effect  upon  the  tissues  as  to  whether 
the  reaction  will  be  short  or  long,  great  or  little. 

This  period  of  reaction  is  in  two  stages,  (1)  of  stimulation,  (2)  of 
relaxation.  In  the  first  stage  the  bloodvessels  are  constricted,  hence 
the  supply  of  blood  is  lessened  in  the  tissues  directly  affected;  in  the 


190  NON-OPERATIVE  METHODS  OF  TREATMENT 

second  stage  the  walls  of  the  bloodvessels  are  relaxed,  thereby  increasing 
the  blood-supply  to  the  parts  immediately  affected.  It  is  estimated 
that  the  cutaneous  bloodvessels  are  capable  of  accommodating  60 
per  cent,  of  the  blood  of  the  body,  hence  baths  have  much  to  do  in 
controlling  the  distribution  of  the  blood. 

Temperature. — The  temperature  of  the  water  is  a  most  essential 
factor  in  the  successful  application  of  the  bath.  By  regulating  the 
temperature  it  is  possible  to  obtain  a  stimulating  or  relaxing  eft'ect 
and  to  accomplish  the  effect  quickly  or  slowly  according  to  the  degree 
of  temperature. 

The  effect  of  cold  upon  the  respiration  is  that  of  stimulation.  The 
respiratory  act  is  deepened,  thus  oxidation  is  increased  and  an  excess  of 
carbon  dioxide  is  thrown  off.  By  stimulating  the  heart  and  contracting 
the  peripheral  bloodvessels  the  blood  tension  is  heightened.  Cold 
baths  at  daily  intervals,  when  properly  administered,  will  tend  to 
increase  the  general  nutrition;  to  promote  secretions  and  excretions 
and  in  time  to  improve  the  functional  activity  and  structural  develop- 
ment of  the  body. 

The  primary  effect  of  moderate  degrees  of  heat  is  mildly  stimulating 
and  the  secondary  effect  is  that  of  relaxation.  The  primary  effect  of 
high  degrees  of  heat  is  at  first  stimulating  then  relaxing. 

Duration. — A  bath  or  douche  of  short  duration,  whether  hot  or  cold, 
is  stimulating,  and  in  proportion  to  the  degree  of  heat  or  cold.  With 
the  continuance  of  the  bath  the  stage  of  relaxation  comes  and  con- 
tinues in  proportion  to  the  degree  of  heat  or  cold,  to  the  duration 
of  the  bath  and  to  the  physical  resistance  of  the  individual. 

The  Position  of  the  Patient. — The  position  of  the  patient  while  taking 
the  bath  or  douche  has  much  to  do  with  the  results.     (See  page  197.) 

Rest  and  Friction  after  the  Bath. — When  a  stimulating  effect  is  desired 
the  bath  should  be  followed  by  friction  of  the  body  with  a  coarse  towel, 
and  should  be  both  preceded  and  followed  by  systematic  exercise  to 
promote  the  circulation  and  thus  favor  a  prompt  reaction. 

Sedative  baths  should  be  followed  by  rest  and  the  body  should  be 
dried  with  a  soft  towel  without  friction.  The  idiosyncrasies  and  state 
of  health  of  the  individual  must  be  considered  in  the  enforcement  of 
these  rules. 

A  short  cold  bath  and  to  a  lesser  degree  a  short  hot  bath  are  stimulating. 
Blood  is  first  forced  to  the  deeper  parts  of  the  body;  the  respirations 
are  deepened.  This  in  turn  stimulates  the  heart  and  thereby  increases 
the  blood  supply  to  the  body.  In  this  manner  the  tissues  are  better 
nourished  and  all  functions  of  organs  are  more  active.  All  this  leads  to 
a  heightened  power  of  resistance  to  morbid  processes.  If  the  tissues 
react  promptly  to  the  stimulating  effects  of  the  bath  there  is  a  general 
invigoration  of  the  whole  body,  and  this  is  increased  by  friction  of  the 
body  and  exercise. 

Time  for  Taking  a  Bath. — As  a  rule  a  stimulating  bath  should  be  taken 
in  the  morning  upon  rising  and  a  sedative  bath  in  the  evening  before 
retiring. 


HYDROTHERAPY  191 

Varieties  of  Baths. — Sponge  Bath. — The  sponge  bath  has  a  stimulating 
effect  if  taken  hot,  cold,  or  alternating.  The  hot  sponge  bath  is  seldom 
employed.  In  the  cold  sponge  bath  there  is  a  stimulating  action. 
After  exercise  it  is  invigorating  and  refreshing.  The  temperature  of  the 
bath-ranges  from  50°  to  70°  F.  It  is  best  taken  standing  in  a  bath-tub. 
When  the  individual  is  not  accustomed  to  cold  baths  it  would  be  well 
to  begin  with  a  temperature  of  70°  to  80°  F.  and  gradually  lower  the 
temperature  to  50°  F. 

Occasionally  the  alternating  sponge  bath  is  recommended  for  its 
stimulating  qualities.  Two  basins  are  placed  side  by  side  in  a  bath- 
tub, one  filled  with  water  at  110°  the  other  at  50°  F.  Standing  in 
the  bath-tub  the  individual  quickly  alternates  from  one  basin  to  the 
other,  using  a  sponge.  Vigorous  friction  with  a  coarse  towel  should 
follow  the  sponge  bath,  after  which  some  light  exercise  should  be 
indulged  in,  such  as  walking  briskly. 

Sponging  in  Bed. — When  for  any  reason  the  patient  cannot  stand 
throughout  the  bath  she  may  be  sponged  in  bed.  She  lies  upon  a  rubber 
sheet  and  is  covered  by  a  woollen  blanket.  The  body  should  be  kept 
covered  during  the  bath,  so  far  as  possible.  Equal  parts  of  alcohol 
and  water  are  applied  at  a  temperature  of  70°  to  75°. 

Fig.  84 


.^ 


Portable  tub. 

Showee  Bath. — The  action  of  the  cold  shower  is  stimulating.  For 
convenience,  the  adjustable  shower  bath  with  a  rubber  sheet  attach- 
ment is  preferred.  This  can  be  arranged  to  overhang  the  bath-tub  with 
little  expense.  A  less  expensive  apparatus  consists  of  an  adjustable 
spray  attached  to  the  spigot  of  the  bath-tub  by  a  flexible  tube  several 
feet  in  length.  In  the  absence  of  suitable  plumbing,  such  as  pray  may 
be  attached  to  a  fountain  syringe.  With  such  an  apparatus  the  patient 
may  stand  in  a  tub. 

The  force  of  the  spray  as  well  as  the  temperature  of  the  water 
determine  the  stimulating;  effect  of  the  bath.     The  colder  the  water 


192 


XOX-OPERATIRE  METHODS  OF   TREATMENT 


and  the  greater  the  force  the  more  rapid  and  more  pronounced  the 
reaction.  As  ^\ith  the  sponge  bath  so  with  the  shower,  the  water 
may  be  cold  or  graduated  from  lukewarm  to  cold;  again,  it  may  be 
alternating  from  hot  to  cold.  The  spray  is  directed  first  to  the  shoulders, 
then  to  the  chest,  back,  abdomen,  and  extremities,  and  should  not,  as 
a  rule,  exceed  thirty  seconds  in  time,  and  should  never  be  prolonged 
bevond  two  or  three  minutes. 


Fig.  So 


Shower  bath. 


As  with  all  cold  baths,  the  shower  bath  is  best  taken  in  the  morning 
after  light  exercise,  and  should  be  followed  by  rubbing  with  a  coarse 
towel. 

The  graduated  shower  bath  should  begin  at  about  S0°  F.,  and  the 
temperature  lowered  2°  each  day  until  50°  F.  are  reached. 

The  alternating  spray  begins  at  100°  to  114°  F.  and  abruptly  changes 
to  50°  to  70°  F. 

The  R^lf  Bath.— The  tub  is  filled  with  water  sufficient  to  cover 
half  the  body,  with  the  patient  in  the  recumbent  position.  The  bath 
may  be  hot  or  cold  according  to  the  indication.  The  same  precautions 
should  be  taken  as  in  the  other  varieties  of  baths.  If  a  stimulating 
effect  is  desired  the  temperature  of  the  water  may  be  fixed  at  80°  F.;  in 


HYDROTHERAPY  193 

this  the  patient  lies  for  a  few  minutes,  then  rises  for  a  short  cold  shower 
and  vigorous  friction  of  the  body. 

If  a  sedative  effect  is  desired  the  temperature  of  the  water  should 
be  about  80°  F.,  and  the  duration  of  the  bath  twenty  to  thirty  minutes, 
after  which  the  body  is  dried  with  a  soft  towel,  without  friction.  The 
body  is  then  "^Tapped  in  a  woollen  blanket  or  bath  robe.  It  would  be 
well  for  the  patient  to  lie  on  a  couch  or  bed  for  a  half  hour  or  more 
after  such  a  bath. 

The  Full  Tub  Bath. — The  full  tub  bath  may  be  stimulating  or 
sedative  according  to  the  temperature  of  the  water  and  the  length  of 
the  application.  The  prolonged  hot  tub  bath  is  sedative,  and  should 
not  be  preceded  by  exercise.  It  is  best  taken  at  bedtime  and  should 
not  be  followed  by  vigorous  rubbing  or  exercise.  The  temperature 
of  the  hot  bath  ranges  from  100°  to  114°  F.,  and  the  duration  is  ten  to 
thirty  minutes,  according  to  the  reaction  of  the  individual  and  the 
effect  required.    Long  hot  baths  frequently  repeated  are  debilitating. 

The  hotter  the  bath  the  quicker  and  the  more  pronounced  the 
reaction. 

The  warm  tub  bath  at  75°  to  90°  F.  is  sedative  in  its  effect  but  the 
reaction  comes  slowly.  It  is  subject  to  the  same  regulations  as  the  hot 
bath. 

The  Cold  Tub  Bath. — With  the  water  at  50°  F.  .the  bath  is  decidedly 
stimulating.  In  order  that  the  reaction  will  not  be  delayed  it  should 
be  preceded  by  sufficient  exercise  to  stimulate  the  circulation.  As 
with  all  cold  baths  it  is  best  taken  in  the  morning  upon  rising,  and 
should  be  followed  by  vigorous  rubbing  with  a  coarse  towel.  The 
duration  of  the  plunge  should  not  exceed  thirty  seconds  unless  the 
individual  is  very  vigorous.  Depression  will  follow  a  prolonged  cold 
bath.  Chill,  languor,  or  drowsiness  coming  on  after  the  bath  are 
contra-indications.  Old  age  is  a  contra-indication,  as  is  arteriosclerosis 
and  other  evidences  of  senility. 

The  Sitz  Bath. — Sitz  baths  are  applied  to  the  pelvis  and  its  contents; 
they  operate  upon  this  region  of  the  body  as  does  a  full  bath  upon  the 
general  system.    They  are  giA^en  cold,  hot,  or  graduated. 

Cold  Sitz  Baths. — Cold  sitz  baths  are  given  at  a  temperature  of  50° 
to  75°  F.  They  are  seldom  employed  and  are  of  little  value.  Their 
duration  should  not  exceed  one  to  five  minutes,  after  which  the  body 
should  be  quickly  dried,  and  a  rest  of  a  half  hour  or  more  should  be 
enjoined. 

•  The  cold  sitz  bath  is  indicated  in  amenorrhea  not  dependent  upon 
pregnancy,  in  lactation  atrophy  of  the  uterus,  in  muscular  insufficiency 
of  the  uterus  causing  hemorrhage  and  leucorrhea,  and  in  subinvolution, 
passive  congestion,  and  chronic  inflammation  of  the  uterus. 

The  contra-indications  are  pregnancy,  menstruation,  acute  pelvic 
inflammation,  and  spastic  conditions  of  the  bladder. 

Prolonged  Hot  Sitz  Bath. — The  prolonged  hot  sitz  bath  is  of  value 
in  relieving  congestion  and  in  favoring  the  absorption  of  pelvic  exudates. 

Hot  sitz  baths  are  usually  taken  at  bedtime,  and  have  a  sedative 
13 


194  NON-OPERATIVE  METHODS  OF  TREATMENT 

effect  on  the  tissues  directly  affected.  The  temperature  of  the  water 
ranges  from  110°  to  114°  F.,  and  is  continued  from  twenty  to  thirty 
minutes. 

The  graduated  sitz  baths  begin  at  a  temperature  of  about  100°  F., 
and  cold  water  is  added  until  the  patient  begins  to  feel  chilly,  when 
she  is  removed  from  the  bath,  dried,  and  placed  in  bed  between  warm 
blankets.    The  effect  is  slightly  stimulating. 

Sea  Bath. — Sea  bathing  is  very  beneficial  on  account  of  its  stimu- 
lating effects,  if  taken  judiciously.  The  benefit  derived  does  not  depend 
solely  upon  the  effect  of  the  water.  The  change  of  scene,  diet,  and  air 
are  most  helpful;  these  factors,  together  with  the  cool  plunges  and  the 
invigorating  effects  of  the  surf,  act  as  a  tonic  to  the  general  system. 
If  prolonged  the  effect  may  be  exhaustion,  hence  the  temptation  to 
remain  long  in  the  water  must  be  resisted.  As  soon  as  the  sense  of 
chilliness  is  felt  the  bath  must  be  discontinued  and  the  body  rubbed 
with  a  coarse  towel.  These  baths  should  only  be  taken  in  the  sunshine, 
when  the  reaction  will  be  more  prompt.  They  are  of  special  value 
because  of  the  attending  muscular  exertion.  It  is  well  to  take  a  brisk 
walk  on  the  beach  before  and  after  the  bath. 

Salt  Baths. — The  addition  of  two  five-pound  packages  of  sea  salt 
to  the  cold  tub  bath  adds  to  the  stimulating  effects  of  the  bath; 
furthermore,  sea  salt  added  to  the  hot  tub  bath  augments  the  sedative 
effect. 

The  Turkish  Bath. — To  equip  the  home  with  a  turkish  bath 
requires  a  specially  constructed  apparatus.  A  cabinet  may  be  made 
of  a  steel  frame  covered  with  a  double  layer  of  rubber  sheeting.  In 
the  top  is  an  opening  through  which  the  head  protrudes.  Enclosed 
within  the  cabinet  is  a  stool  on  which  the  patient  sits,  and  under  this 
stool  is  placed  an  alcohol  lamp  or  gas  stove.  The  cabinet  should  be 
heated  for  ten  minutes  before  the  patient  enters  it. 

The  hot-air  bath  should  continue  ten  to  twenty  minutes,  and  imme- 
diately upon  leaving  the  cabinet  the  patient  should  be  given  a  hot 
shower  bath  at  a  temperature  of  100°  to  110°  F.,  this  to  be  followed 
by  a  cold  shower  of  50°  to  75°  F.,  and,  finally,  there  should  be  vigorous 
rubbing  of  the  body  with  a  coarse  towel,  after  which  the  patient  is 
wrapped  in  a  blanket  and  placed  on  a  couch  for  a  half-hour  or  more. 
Water  should  be  drunk  freely  both  before  and  during  the  bath. 

Free  perspiration  is  usually  excited  within  ten  minutes  of  the  begin- 
ning of  the  bath.  If  throbbing  of  the  head  occurs  or  the  pulse  reaches 
120  to  the  minute  the  bath  must  be  discontinued.  A  cold  cloth,  to  the 
head  will  add  to  the  comfort  of  the  patient. 

The  Russian  Bath. — The  apparatus  and  general  technic  of  the 
bath  is  the  same  as  in  the  Turkish  bath,  with  the  exception  that  a  kettle 
filled  with  water  is  placed  over  the  stove  to  generate  steam. 

The  Sheet  Bath. — A  muslin  sheet  is  wrung  out  in  iced  water  and 
wrapped  about  the  body.  With  a  wet  towel  the  attendant  slaps  the 
body  vigorously.  Sharp,  quick  strokes  are  kept  up  for  from  two  to 
five  minutes.    The  sheet  is  then  removed  and  the  skin  vigorously  rubbed 


HYDROTHERAPY  195 

with  a  coarse  towel.  The  patient  is  then  placed  in  bed,  WTapped  in  a 
blanket.  Such  a  bath  is  stimulating  in  its  effects,  and  is  best  given 
in  the  morning. 

Bathing  during  the  Menstrual  Period. — There  is  no  reason  why  a  woman 
who  is  in  the  habit  of  taking  daily  baths  should  be  deprived  of  them 
while  menstruating.  A  menstruating  woman  in  good  health  will  suffer 
no  ill  eft'ects  from  a  hot  or  cold  bath  provided  certain  precautions  are 
taken,  and  it  may  be  said  of  all  women  that  their  personal  comfort  and 
general  health  will  be  the  better  if  such  daily  baths  are  taken  during 
the  menstrual  period.  The  rules  of  hygiene  demand  that  a  daily 
tepid  bath  (80°  to  90°  F.)  be  taken  throughout  the  menstrual  period. 
Women  should  be  cautioned  against  the  dangers  of  chilling  the  body 
during  and  following  the  bath.  Sea-bathing,  for  this  reason,  is 
dangerous. 

The  Nauheim  Bath. — The  stimulating  effect  of  a  bath  may  be  aug- 
mented and  made  more  agreeable  by  the  addition  of  certain  chemical 
substances.  In  this  manner  a  pronounced  reaction  is  eff'ected  which 
alters  the  distribution  of  the  blood  so  that  the  congestion  of  internal 
organs  is  relieved.  The  number  of  red  blood  cells  is  increased  in  the 
circulating  blood,  the  tone  of  the  tissues,  including  the  heart,  is  increased, 
and  by  stimulating  the  trophic  central  nervous  system  the  general 
tissue  metabolism  is  increased.  By  adding  to  the  bath  water  a  chemical 
stimulus  the  eff'ect  is  most  agreeable  and  prompt.  The  addition  of  salt 
augments  the  stimulating  qualities,  and  because  of  this  the  individual 
will  take  the  bath  at  a  lower  temperature. 

The  Xauheim  bath  consists  of  a  bath  containing  salt,  calcium  chloride, 
and  carbonic  acid  gas,  in  var^dng  proportions.  The  temperature  of 
the  bath  varies  from  80°  to  95°  F.,  and  should  be  continued  five  to 
twenty  minutes.  Kt  the  beginning  of  the  treatments  there  should  be 
added  to  the  tub  of  water  3  to  5  pounds  of  sea  salt,  2  to  4  ounces  of 
calcium  chloride,  and  one-half  box  of  triton  salts.  After  each  third 
or  fourth  bath  a  little  more  of  each  salt  should  be  added  if  the  patient 
responds  well  to  the  baths.  The  temperature  of  the  bath  which  begins 
at  75°  F.  is  gradually  lowered  to  85°  F.,  provided  the  change  is  agree- 
able to  the  patient.  xAfter  the  bath  the  body  is  gently  dried  with  warm 
towels,  a  hot  drink  of  milk  or  tea  is  taken,  and  the  patient  lies  down  for 
a  rest  of  an  hour  or  two. 

It  will  be  seen  that  these  baths  are  eminently  stimulating,  and  as 
such  are  applied  to  individuals  suft'ering  from  chlorosis  with  accompany- 
ing amenorrhea,  faulty  development  of  the  genitalia,  subinvolution 
of  the  uterus,  and  all  lesions  of  the  pelvic  organs  which  are  associated 
with  pelvic  congestion,  such  as  chronic  metritis,  pelvic  cellulitis,  and 
salpingitis.  They  are  also  said  to  add  tone  to  relaxed  pelvic  and  abdomi- 
nal organs  as  seen  in  general  visceroptosis.  Neurasthenic  conditions 
are  favorably  influenced  by  these  baths.  The  nervous  manifestations 
of  the  change  of  life  are  greatly  relieved  by  the  judicious  application  of 
these  baths.  It  is  imperative  that  they  should  be  given  under  the 
direction  of   the    physician,   because  the  reaction  of   the   individual 


196 


NON-OPERATIVE  METHODS  OF  TREATMENT 


depends  upon  the  strength  of  the  baths,  upon  their  temperature  and 
duration. 

The  Therapeutic  Application  of  Baths. — Sedative  Bath  (Hot). — The 
relaxing  effect  of  a  prolonged  warm  bath  has  been  noted.  It  follows 
that  such  a  bath  would  be  applicable  to  nervous  and  excitable  indi- 
viduals, to  insomnia,  to  spastic  dysmenorrhea,  to  the  various  nervous 
manifestations  of  the  climacteric,  and  to  pelvic  congestion  from  whatever 
cause.  They  are  best  given  in  the  evening  just  before  retiring,  and 
should  be  followed  by  a  drink  of  hot  milk  or  hot  lemonade. 

Stimulating  Bath  {Cold). — Inasmuch  as  the  cold  bath  is  stimulating 
to  the  vasomotor  nerves,  to  the  superficial  muscles,  and  indirectly 
quickens  the  general  circulation,  driving  the  blood  to  internal  organs, 
thereby  stimulating  the  functions,  of  these  organs,  it  follows  that  the 


Fig.  86 


Vaginal  douche.     Patient  lying  upon  her  back.    The  vagina  is  distended. 


cold  stimulating  bath  is  of  special  value  in  neurasthenic  states,  in 
general  malnutrition,  chlorosis  and  other  forms  of  anemia,  in  amenor- 
rheics,  especially  when  associated  with  chlorosis  and  in  visceroptosis 
with  relaxation  of  the  supports  to  the  pelvic  organs.  The  bath  is  best 
given  in  the  morning,  and  should  be  followed  by  brisk  rubbing,  with  a 
coarse  towel  and  moderate  exercise  if  the  condition  of  the  patient 
will  permit. 

The  Vaginal  Douche. — One  of  the  most  valuable  agencies  in  the 
treatment  of  diseases  of  women  is  the  vaginal  douche.  Like  the  bath 
its  modus  operandi  is  not  generally  understood,  and  when  wrongly 
applied  is  capable  of  doing  harm,  but  when  rightly  applied  the  vaginal 
douche  acts  as  a  stimulant  to  the  vasomotor  nerves  and  to  the  uterine 
musculature.    As  a  cleansing  agency  it  is  indispensable,  and  as  a  means 


HYDROTHERAPY  '  197 

of  conveying  certain  remedies  to  the  vagina  and  vaginal  portion  of  the 
cervix  it  is  of  service. 

Physiological  Action. — The  physiological  action  depends  upon  the 
manner  of  its  application.  The  posture  of  the  patient  and  the  duration 
and  temperature  of  the  douche  are  all  essential  factors  in  obtaining  the 
desired  results. 

Posture. — For  all  purposes  the  recumbent  posture  is  essential  in  order 
that  the  fluid  may  come  in  direct  contact  with  the  vault  of  the  vagina 
and  cervix  and  indirectly  with  the  pelvic  structures. 


Fig.  87 


\ 


Kelly  pad. 


The  position  should  be  such  as  to  permit  the  patient  to  lie  in  comfort, 
without  exertion,  and  without  fear  of  soiling  the  bed  or  couch.  The 
complaint  is  frequenth'  made  that  hot  douches  are  exhausting;  the 
explanation  usually  lies  in  a  faulty  posture.  Lying  upon  an  uncom- 
fortable douche-pan  that  is  repeatedly  oA'erfilling,  requiring  its  removal 
from  time  to  time  in  the  process  of  the  douche,  is  a  source  of  annoyance, 
and  is  exhausting.  A  small  spout  placed  at  the  upper  end  of  a  metallic 
douche-pan,  to  which  a  rubber  tube  is  attached,  will  serve  to  carry 
the  douche  water  from  the  pan  to  a  bucket  at  the  side  of  the  bed. 
If  the  bed  is  firm,  a  Kelly  pad  will  serve  as  a  substitute  for  the 
douche-pan. 

For  cleansing  purposes  an  ordinary  rubber  douche  bag,  holding  four 
quarts,  will  serve  the  purpose,  but  when  the  douche  must  be  long 


198 


NON-OPERATIVE  METHODS  OF   TREATMENT 


continued  it  is  advisable  to  provide  a  receptacle  holding  two  to  four 
gallons  of  water.  For  this  purpose  the  author  usually  has  a  galvan- 
ized zinc  or  tin  bucket  made.  It  has  a  capacity  of  four  gallons;  a 
small  spout  is  attached  near  the  bottom,  to  which  a  rubber  tubing  is 
attached.  With  such  a  contrivance  and  the  bed-pan  already  described 
a  prolonged  douche  can  be  given  without  discomfort  to  the  patient 
and  without  exhausting  her  strength. 


Fig.  88 


Vaginal  douche. 


The  reservoir  should  not  be  placed  higher  than  four  feet  above  the 
hips;  if  pain  is  caused  by  the  impact  of  the  douche  water  it  should  be 
lowered. 

A  light  woollen  blanket  is  thrown  over  the  patient  while  she  is  taking 


HYDROTHERAPY  199 

the  douche  and  the  temperature  of  the  room  should  be  maintained 
at  75°  to  80°  F. 

Temperature. — The  temperature  of  the  douche  water  is  an  important 
factor  and  largely  governs  the  effect  of  the  douche.  A  temperature  of 
110°  to  120°  F.  is  well  borne.  Cold  douches  are  injurious  and  cannot  be 
too  strongly  condemned.  The  pernicious  habit  of  taking  cold  douches 
to  prevent  conception  and  to  delay  the  menstrual  period  is  productive 
of  much  harm  in  creating  a  pelvic  congestion.  Cold  douches  have 
been  recommended  for  chronic  metritis  (Skutsch),  for  prolapsus  uteri, 
hyperemia  uteri,  and  climacteric  hemorrhages  (Kisch),  but  the  author 
cannot  indorse  these  suggestions. 

Duration. — The  duration  of  the  douche  is  second  only  in  importance 
to  the  temperature.  A  hot  douche  of  short  duration  (three  to  five 
minutes)  stimulates  the  vasomotor  nerves  and  the  uterine  musculature. 
In  so  doing  the  vaginal  cavity  is  not  only  cleansed  but  the  uterus  is 
made  to  contract  and  the  bloodvessels  of  the  pelvis  are  constricted, 
thereby  raising  the  blood  pressure.  With  the  hot  douche  prolonged 
for  a  period  of  ten  to  twenty  minutes  the  uterine  musculature  relaxes, 
the  caliber  of  the  vessels  widens,  and  congestion  is  relieved. 

From  this  action  of  the  hot  douche  it  is  seen  that  hemorrhages  from 
the  uterus  are  best  controlled  by  a  short,  hot  douche;  the  effect  is  due 
to  uterine  contraction.  Leucorrheal  discharges  arising  from  the  uterus 
are  influenced  in  like  manner.  The  great  purpose  of  the  short,  hot 
douche  is  the  cleansing  of  the  vagina.  The  prolonged  hot  douche  is  a 
most  efficient  means  of  relieving  pelvic  congestion,  wherever  located 
within  the  pelvis,  and  in  favoring  the  absorption  of  inflammatory 
exudates. 

Time  of  Application. — The  time  of  application  will  depend  upon  the 
indication  as  well  as  upon  convenience.  When  given  for  cleansing 
purposes  the  amount  and  character  of  the  secretions  will  determine 
the  quantity  and  frequency  of  the  douche.  When  the  discharge  is 
profuse,  irritating,  and  odorous,  the  douche  should  be  repeated  two 
or  more  times  daily,  but  otherwise  a  single  morning  douche  will 
suffice. 

The  judicious  employment  of  cleansing  vaginal  douches  will  largely 
prevent  the  irritating  effects  of  uterine  discharges  and  the  development 
of  vulvovaginitis  in  the  presence  of  a  discharge  from  an  infected  uterus. 
It  must  be  borne  in  mind  that  hot  douches  too  freely  given  macerate 
the  vaginal  and  vulvar  epithelium  and  render  the  underlying  tissues 
susceptible  to  infection.  In  the  presence  of  a  pelvic  congestion  or  an 
inflammatory  exudate  in  the  pelvis  the  hot  douche  should  not  only 
be  prolonged  ten  to  twenty  minutes,  but  in  order  that  the  effect  may 
be  continuous  these  douches  should  be  repeated  every  four  to  eight 
hours. 

The  duration  of  the  treatment  depends  solely  upon  the  results 
obtained.  As  long  as  there  is  an  active  congestion  the  douches  must 
be  given  at  frequent  intervals,  but  as  the  congestion  subsides  the  inter- 
vals between  douches  are  lengthened,  but  the  duration  of  the  douche 


200 


NON-OPERATIVE  METHODS  OF  TREATMENT 


is  not  shortened.  It  is  not  only  desired  that  rehef  be  given  for  the 
time  being,  but  that  the  results  may  be  permanent;  hence  the  douches 
must  be  persisted  in  so  long  as  there  is  any  evidence  of  the  preexisting 
lesion. 

Medicated  Vaginal  Douche. — Antiseptic  solutions  are  frequently 
applied,  but  their  value  is,  as  a  rule,  uncertain.  The  vast  majority  of 
infections  are  located  above  the  external  os  and  hence  cannot  be  reached 
by  the  douche.  In  such  cases  the  vaginal  douche  is  of  no  value  as  an 
antiseptic  agent  and  serves  solely  the  purpose  of  cleansing  the  vagina 
and  in  relieving  the  congestion  of  the  structures  lying  above  the  vagina, 
hence  sterile  water  is  just  as  effective  as  an  antiseptic  solution;  the 
effect  is  thermic,  not  chemic. 

It  is  only  when  the  vaginal  and  vulvar  tissues  are  infected  that  the 
antiseptic  douche  possesses  special  virtues;  such  instances  are  relatively 
rare.  It  is  therefore  seen  that  antiseptic  vaginal  douches  have  little 
advantage  over  aseptic  douches.  When  the  discharge  has  a  foul  odor, 
as  is  the  case  with  advanced  cancer,  permanganate  of  potassium  or 
formalin  will  serve  to  correct  the  odor. 

All  sorts  of  antiseptics  have  been  used.  The  author's  preference  is 
for  formalin,  1  to  2000  to  1  to  4000.  It  is  an  effective  deodorizer  and 
antiseptic;  the  author  employs  it  as  a  vaginal  douche  to  the  exclusion 
of  all  other  antiseptics. 

Fig.  89 


Intra-uterine  douche.     The  douche  point  is  directed  to  the  cervix  by  passing  along  the  palmar 

surface  of  the  finger. 


Intra-uterine  Douche.^ — The  intra-uterine  douche  has  a  limited  field 
of  usefulness,  and  is  capable  of  much  harm  as  compared  with  the 


HYDROTHERAPY 


201 


vaginal  douche.  Indeed,  in  the  author's  judgment  there  is  no  great 
indication  for  intra-uterine  douches  in  gynecological  practice;  it  is  largely 
an  obstetrical  procedure,  and  in  obstetrical  practice  it  has  its  limitations. 


Fig.  90 


Intra-uterine  douche. 


Limitations. — It  is  of  little  value  in  gynecological  practice  because 
foreign  particles  can  be  dislodged  from  the  cavity  of  the  uterus  by 
means  of  the  swab,  fingers,  curet,  and  forceps,  and  medicinal  agencies 
can  be  applied  to  the  endometrium  more  effectively  and  with  greater 
safety  by  means  of  the  swab.  In  intra-uterine  douches  there  is  always 
the  danger  of  forcing  fluids  from  the  uterus  into  the  tubes  and  on  to 
the  peritoneum.  This  danger  is  particularly  imminent  in  the  puerperal 
uterus. 

Physiological  Action. — The  action  of  the  hot  intra-uterine  douche  is 
stimulating  if  given  over  a  short  period;  it  stimulates  the  vasomotor 
nerves,  the  vessel  walls,  and  the  uterine  musculature.  It  also  serves 
to  cleanse  the  uterine  cavity.  "\ATien  long  continued  the  effect  is  to 
relax  the  uterine  musculature  and  the  walls  of  the  bloodvessels.  The 
apparatus  differs  from  that  of  the  vaginal  douche  only  in  the  douche 
point,  which  is  longer  and  is  provided  with  a  return  flow. 

Technic. — The  technic  of  an  intra-uterine  douche  is  as  follows: 
The  patient  is  placed  upon  a  table  or  firm  couch  or  bed.  If  she 
is  weak,  every  means  should  be  employed  to  conserve  her  strength; 


202  NON-OPERATIVE  METHODS  OF  TREATMENT 

she  should  he  lengthwise  of  the  bed,  and  a  Kelly  pad  or  bed-pan  with 
an  exit  spout  should  be  placed  under  the  hips.  If  it  is  possible  to  move 
her  without  exhausting  her  strength  or  causing  pain,  it  is  better  to 
place  her  crosswdse  of  the  bed  with  the  hips  well  to  the  margin  of  the 
bed.  The  feet  of  the  patient  may  rest  upon  two  chairs  placed  at  the 
side  of  the  bed. 

The  vulva  should  be  washed  with  green  soap  and  sterile  water  followed 
by  lysol  or  creolin  solution  or  painted  with  3  per  cent,  tincture  of 
iodine  solution.  A  sterile  bivalve  speculum  is  inserted  into  the  vagina 
and  the  cervix  exposed  to  view.  A  sterile  reservoir,  holding  two  to 
four  quarts  of  sterile  normal  salt  solution,  or  a  mild  antiseptic  such  as 
formalin  1  to  4000  or  bichloride  of  mercury  1  to  4000  is  placed  about 
two  feet  about  the  level  of  the  hips.  This  reservoir  is  provided  with 
a  sterile  rubber  tubing  and  glass  or  metallic  douche  point. 

The  temperature  of  the  douche  solution  ranges  from  110°  to  120°  F., 
which  is  accurately  determined  by  a  bath  thermometer.  Under  direct 
inspection  the  douche  point  is  guided  through  the  cervix  into  the 
cavity  of  the  uterus.  Before  introducing  the  douche  point  into  the 
uterus  a  slow  stream'  of  solution  should  be  allowed  to  flow  in  order 
that  all  air  may  be  expelled.  The  solution  is  then  allowed  to  flow  into 
the  uterine  cavity  at  a  low  pressure,  taking  care  that  there  is  a  free 
return  flow. 

Fig.  91 


Leonard's  uterine  douche. 

While  giving  the  douche,  chilling  of  the  body  should  be  avoided  by 
providing  a  warm  temperature  for  the  room  and  a  covering  of  blankets 
for  the  patient. 

i\.fter  completing  the  douche  the  external  genitals  are  dried  and  the 
patient  is  placed  comfortably  in  bed.  If  iodine  is  used  to  disinfect 
the  vulva  it  is  well  to  remove  the  iodine  in  part  by  bathing  the  painted 
surface  with  alcohol;  this  will  avoid  subsequent  irritation. 

The  virtue  of  the  intra-uterine  douche  lies  largely  in  its  mechanical 
and  thermic  effects;  therefore  sterile  water  or  normal  salt  solution  will 
be  less  dangerous  and  perhaps  equally  as  effective  as  antiseptics. 

When,  however,  antiseptic  solutions  are  given  they  should  be  greatly 
attenuated  because  of  the  absorbing  power  of  the  uterus  and  the  danger 
of  forcing  the  solution  into  the  peritoneal  cavity  through  the  Fallopian 
tubes. 

Saline  Injections. — The  injection  of  a  sterile  physiological  solution 
of  salt  into  the  circulation  of  the  blood  is  recognized  as  one  of  the  most 


HYDROTHERAPY  203 

valuable  therapeutic  agencies  at  the  command  of  the  physician.  As  a 
non-operative,  life-saving  agency,  normal  salt  solution  has  no  equal. 

General  Indications. — Normal  salt  solution  finds  its  greatest  indication 
in  the  treatment  of  shock  from  loss  of  blood.  It  is  also  of  great  value 
in  the  treatment  of  renal  insufficiency,  general  sepsis,  and  in  uncontrol- 
lable vomiting  following  operations,  and  as  a  routine  procedure  after 
prolonged  operations  for  the  purpose  of  relieving  depression  and 
quenching  the  thirst. 

For  fear  of  increasing  the  blood  pressure,  normal  salt  injections 
should  not  be  given  in  postoperative  hemorrhages  until  the  bleeding 
vessels  are  secured. 

The  choice  of  the  method  of  its  administration  is  governed  by  the 
urgency  of  the  indication.  When  prompt  action  is  demanded  intra- 
venous injections  should  be  employed.  When  there  is  less  urgency, 
hypodermoclysis  is  the  method  of  choice;  and  when  the  depression 
is  but  slight,  the  diminution  in  the  secretions  of  the  kidney  not  alarming, 
or  the  loss  of  blood  not  great,  enterocylsis  is  preferred  unless  contra- 
indicated  by  conditions  of  the  bowel,  such  as  obstruction,  recent  oper- 
ations upon  the  lower  bowel,  and  injuries  to  the  bowel  wall  acquired 
in  operation. 

Enteroclysis. —  Technic. — The  reservoir  for  containing  the  solution 
may  be  a  rubber  bag  holding  two  to  four  quarts  or  a  graduated  glass 
receptacle.  To  the  reservoir  is  attached  a  rubber  tube  several  feet  in 
length,  on  the  end  of  which  is  a  rectal  douche  point  made  of  glass 
or  hard  rubber.  This  apparatus  is  sterilized  by  boiling  in  water  or  by 
placing  in  an  instrument  sterilizer.  A  sterile  thermometer  should  be 
provided  by  which  the  temperature  of  the  solution  may  be  accurately 
measured. 

Quantity  of  the  Solution. — One  to  two  quarts  of  sterile  normal  salt 
solution  are  placed  in  the  reservoir  at  a  temperature  of  110°  F.  If 
additional  stimulation  is  indicated  a  half-ounce  of  whisky  or  brandy 
may  be  added  to  the  salt  solution.  Half  and  half  of  salt  solution  and 
black  coffee  is  an  effective  enema. 

Rapidity  of  Administration. — The  urgency  of  the  indication  and 
the  absorbing  power  of  the  bowel  will  govern  the  rapidity  of  the 
administration. 

As  a  rule  one  to  two  pints  of  the  solution  are  injected  into  the  bowel 
four  to  six  times  in  twenty-four  hours  throughout  the  period  of  de- 
pression, and  the  time  allotted  to  each  injection  will  range  from  five 
to  fifteen  minutes. 

When  the  reaction  has  set  in,  as  indicated  by  the  increase  in  the 
volume  of  the  pulse  and  the  added  quantity  of  urine  secreted,  the 
interval  between  the  injections  should  be  gradually  increased. 

The  continuous  injections  of  normal  salt  solution  in  the  bowel  are 
of  special  value  when  there  is  profound  shock  from  loss  of  blood  or 
grave  and  progressive  general  sepsis.  The  technic  consists  in  elevating 
the  foot  of  the  bed  and  hips  to  an  angle  to  20  to  30  degrees;  the 
rectal  tube  is  inserted  high  in  the  colon;  the  reservoir  is  placed  at  a 


204 


NON-OPERATIVE  METHODS  OF  TREATMENT 


Fig.  92 


low  level  to  provide  but  little  pressure  in  order  that  the  solution  may 
enter  the  bowel  slowly. 

An  hour  should  be  consumed  in  the  injection  of  a  single  pint  of  the 
solution.    These  injections  should  not  be  permitted  to  embarrass  the 
heart  action  by  increasing  the  vascular  tension  beyond  the  ability  of 
the  heart  to  propel  the  blood  current.     Such  an  event 
is  particularly  imminent  when  there  is  faulty  elimi- 
nation from  the  kidneys,  bowel  and  skin. 

Several  degrees  of  temperature  are  lost  in  the 
passage  of  the  solution  through  the  tube,  hence  the 
necessity  of  keeping  the  solution  in  the  reservoir  at 
about  114°  F. 

When  not  contra-indicated  these  continuous,  irriga- 
tions may  be  prolonged  over  many  hours  and  even 
for  a  day  or  two. 

Sooner  or  later  there  is  likely  to  develop  an  irritable 
condition  of  the  bowel,  in  which  event  the  injections 
must  be  discontinued  and  hypodermoclysis  substituted 
if  the  condition  of  the  patient  demands  it. 

Hypodermoclysis.  —  Apparatus. — The  apparatus  is 
identical  to  that  used  in  enteroclysis  with  the  sub- 
stitution of  an  aspirating  needle  for  a  rectal  tube. 

Preparation  of  the   Field  of  Operation.  —  Surgical 
principles  are  to  be  applied  to  the  preparation  of  the 
field  of  operation.     The  part  to  be  injected  should 
be  thoroughly  cleansed  with  green  soap  and  sterile 
water,  dried  with  sterile  gauze  and  finally  scrubbed 
with  alcohol.     A  more  convenient  method  of  sterili- 
zation is  the  painting  of  the  field  with  tincture  of  iodine.     After  com- 
pleting the  injection  the  puncture  is  sealed  with  collodion  and  sterile 
cotton. 

Temperature. — ^The  temperature  of  the  injected  solution  should  be 
112°  F.;  this  will  favor  rapid  absorption  and  a  prompt  reaction. 

Quantity. — The  quantity  of  the  solution  injected  should  not  exceed 
one  pint  and  may  be  repeated  once  in  four  to  six  hours  until  the  reaction 
is  well  established.  From  fifteen  to  thirty  minutes  should  be  consumed 
in  the  injection  of  a  single  pint. 

Massage. — Massage  of  the  injected  area  will  favor  the  absorption  of 

the  solution  and  may  be  carried  on  throughout  the  process  of  injection. 

Technic. — The    point    of    injection    should    be  at  the  seat  of  an 

abundance  of  loose  connective  tissue,  preferably  in  the  breast,  the 

midaxillary  line  three  inches  below  the  axilla,  or  in  the  lumbar  region. 

The  author  has  never  employed  local  anesthesia  before  the  injection, 

because  the  introduction  of  the  aspirating  needle  causes  little  more 

pain  than  the  hypodermic  needle.     When  a  local  anesthetic  is  desired 

a  2  per  cent,  solution  of  the  hydrochlorate  of  cocaine  or  freezing  with 

ethyl  chloride  may  be  employed. 

The  reservoir,  tubing,  and  aspirating  needle  must  be  rendered  sterile 


HYDROTHERAPY 


205 


by  boiling.  A  known  quantity  of  sterile  salt  solution  is  placed  in  the 
reservoir,  and  an  assistant  is  instructed  to  hold  the  reservoir  about 
six  feet  above  the  level  of  the  field  of  operation.  The  operator  allows 
the  solution  to  flow  while  holding  the  tubing  and  needle  upright 
to  expel  the  air  and  the  water  which  has  cooled  in  the  tube.  With 
the  solution  running,  the  needle  is  thrust  obliquely  through  the  skin 
into  the  subcutaneous  connective  tissue,  taking  care  that  it  does  not 
enter  the  muscles.  As  the  solution  infiltrates  the  connective  tissue 
spaces  the  skin  is  raised  and  stretched.    If  the  solution  is  not  readily 


Fig.  93 


Administration  of  normal  salt  solution. 


absorbed,  gentle  massage  of  the  infiltrated  area  will  hasten  the  absorp- 
tion. The  temperature  of  the  solution  in  the  reservoir  should  be  kept 
at  112°  F.  by  the  addition  from  time  to  time  of  a  hot  solution.  When 
the  desired  amount  has  been  injected  the  needle  is  quickly  withdrawn, 
a  finger  is  placed  over  the  puncture  in  the  skin  to  prevent  the  escape 
of  the  fluid  until  the  wound  is  dressed  with  sterile  cotton  and  collodion 
or  sterile  gauze  and  adhesive  straps. 

Intravenous  Injection. — Indications. — This  method  of  administration 
of  normal  salt  solution  is  practically  limited  to  cases  demanding  an 


206  XOX~OPERATIVE  METHODS  OF   TREATMENT 

immediate  reaction.  When  there  has  been  great  loss  of  blood,  the 
lowered  blood  pressure  may  prevent  the  absorption  of  the  salt  solution 
from  the  bowel  and  subcutaneous  connective  tissue,  and  demand  the 
introduction  of  the  solution  directly  into  the  blood  stream. 

In  septicemia  and  uremia,  when  the  blood  pressure  is  high,  it  may 
be  advisable  to  perform  venesection  for  the  removal  of  a  quantity  of 
blood,  and  to  follow  the  withdrawal  of  the  blood  by  the  introduction 
of  an  equal  or  greater  quantity  of  normal  salt  solution. 

Apparatus. — The  apparatus  required  in  intravenous  injections  con- 
sists of  a  graduated  glass  reservoir,  a  thermometer,  a  rubber  tubing 
several  feet  in  length  to  which  is  attached  a  Shober  cannula.  In 
addition  to  these  instruments  there  will  be  required  a  scalpel,  a  pair 
of  small  sharp  pointed,  straight  scissors,  tissue  forceps,  two  small  curved 
needles,  a  needle  holder,  and  No.  2  plain  catgut.  All  instruments, 
as  well  as  the  hands  of  the  operator,  must  be  rendered  sterile  by  the 
usual  methods. 

Local  Anesthesia.  —  A  2  per  cent,  solution  of  cocaine  may  be 
injected  at  the  point  of  incision.  This  should  render  the  operation 
painless. 

Technic. — The  operation  consists  in  bandaging  the  arm  tightly 
above  the  elbow.  An  incision  of  three-quarters  of  an  inch  in  length 
will  suffice  for  the  exposure  of  the  vein.  A  careful  dissection  of  the 
vein  is  then  made,  freeing  it  for  a  distance  of  about  one  inch.  The  vein 
is  ligated  with  catgut  at  the  lower  extremity  of  the  incision.  A  second 
ligature  is  passed  about  the  vein  three-quarters  of  an  inch  above  the 
lower  ligature,  but  is  not  tied  until  the  vein  is  opened  and  the  cannula 
is  in  place.  The  vein  wall  is  grasped  with  a  tissue  forceps  at  a  point 
midway  between  the  ligatures  and  snipped  obliquely  upward,  making 
an  opening  large  enough  to  introduce  a  cannula  into  the  lumen  of  the 
vein.  Before  introducing  the  cannula  the  air  and  cooled  water  in  the 
tube  should  be  allowed  to  flow  out.  The  vein  is  then  tied  snugl}'  over 
the  cannula.  The  compression  above  the  elbow  is  removed,  and  the 
solution  is  permitted  to  flow  into  the  vein. 

When  the  required  amount  of  solution  has  been  injected  a  third 
ligature  is  passed  above  the  second  to  secure  the  proximal  end  of 
the  vein;  the  second  ligature  is  cut  and  removed  and  the  cannula 
withdrawn.  The  incision  in  the  skin  is  then  closed  with  silk,  linen,  or 
horse-hair,  and  the  wound  dressed  in  a  sterile  bandage. 

Quantity. — The  quantity  of  fluid  injected  varies  from  one  to  four 
pints  and  may  be  repeated  in  two  or  more  hours.  As  a  rule  the  injection 
is  not  repeated  but  is  reinforced  by  hypodermoclysis  or  enteroclysis. 

Temperature.— The  temperature  of  the  solution  in  the  reservoir 
should  be  kept  at  105°  F.  This  should  be  accm-ately  measured  by  a 
thermometer  kept  immersed  in  the  solution  in  the  reservoir. 

The  weaker  the  pulse  the  lower  should  the  reservoir  be  held  in  giving 
the  injection  for  fear  of  introducing  the  solution  too  rapidly  into  the 
circulation. 


HYDROTHERAPY  207 

Ice-bag. — A  rubber  ice-bag  is  partly  filled  with  cracked  ice.  This  is 
placed  in  direct  contact  with  the  surface  of  the  body.  If  the  intense 
cold  causes  discomfort  it  may  be  wrapped  in  muslin.  When  the  ice 
has  melted  the  bag  should  be  refilled. 

Simpson  recommends  the  application  of  the  ice-bag  to  the  abdomen 
after  all  abdominal  operations.  He  believes  that  it  will  prevent  the 
development  of  peritonitis  to  a  degree  and  will  have  a  decided  influence 
in  allaying  a  preexisting  inflammation. 


Application  of  ice-bags  to  abdomen. 

Hot  Compresses. — The  continuous  apphcation  of  heat,  either  by 
means  of  a  compress  or  water-bag,  will  have  a  sedative  effect,  and  is, 
therefore,  much  used  in  the  relief  of  pain  from  whatever  cause. 

Compresses  are  made  of  several  layers  of  flannel  or  sterile  gauze 
wrung  out  in  hot  water.  To  retain  the  heat  the  compress  is  covered 
with  oil  silk  or  a  rubber  sheet.  A  hammock  may  be  made  of  a  towel 
with  sticks  at  either  end.  In  this  device  the  clothes  are  wrung  by  a 
twisting  process. 

Hot-water  Bag. — A  rubber  bag  containing  one  to  four  quarts  of  hot 
water,  when  applied  to  the  surface  of  the  body,  will  produce  an  effect 
upon  the  tissues  with  which  it  comes  in  contact  that  varies  with  the 
degree  of  temperature  and  the  time  of  application.  In  a  general  way 
it  may  be  said  that  the  hot-water  bottle  produces  the  same  effect  upon 
the  vasomotor  nerves,  bloodvessels,  and  muscular  tissues  as  does  the 
hot  vaginal  douche;  it  is  at  first,  temporarily  stimulating;  second, 
relaxing  or  sedative. 


208  NON-OPERATIVE  METHODS  OF  TREATMENT 

Water  Drinking. — Water  is  not  sufficiently  appreciated  as  a  remedial 
agent  in  various  modes  of  application ;  this  is  particularly  true  of  water 
taken  into  the  stomach. 

Physiological  Action. — The  physiological  effect  of  drinking  water 
depends  upon  the  quantity  of  water  ingested  and  the  degree  of  tem- 
perature. The  physiological  action  of  water  taken  into  the  stomach 
is  varied.  When  taken  in  large  quantities  it  flushes  the  system  by 
diluting  the  blood,  raising  the  arterial  tension,  and  promoting  the 
excretions  from  the  body,  thus  carrying  away  the  waste  stuffs  from 
the  body  through  the  natural  channels — the  kidneys,  bowels,  and  skin. 

The  peristaltic  activity  of  the  intestines  is  increased,  the  skin  and 
kidneys  secrete  more  freely,  and  the  lungs  are  made  more  active  in 
throwing  off  carbonic  oxide  gas  and  in  taking  in  oxygen. 

Not  only  is  the  elimination  of  the  waste  stuffs  of  the  blood  favored, 
but  also  those  which  are  deposited  in  the  tissues  are  taken  up  by  the 
lymph-  and  blood-streams  and  are  excreted. 

The  temperature  of  the  water  when  taken  into  the  stomach,  and 
the  quality  and  quantity  of  the  water  determine  the  physiological 
effect. 

Heat  and  cold,  when  applied  internally  by  the  drinking  of  water, 
have  the  same  effect  as  when  they  are  applied  externally  in  the  form 
of  a  bath.  It  necessarily  follows  that  the  amount  of  water  ingested 
will  produce  effects  that  are  analogous  to  the  bath,  so  far  as  concerns 
the  length  of  application. 

Pure  water  is  the  first  requisite.  That  it  should  be  free  of  pathogenic 
germs  is  generally  admitted,  but  there  are  other  qualities  which  are 
almost  equally  important.  Water  may  contain  certain  organic  and 
mineral  substances  which  are  injurious  to  the  body.  Mineral  salts  in 
water  are  not  essential  to  the  physical  economy;  sufficient  salts  are 
obtained  from  the  foodstuffs. 

The  function  of  drinking  water  is  in  part  to  absorb  from  the  tissues 
certain  mineral  salts,  rather  than  to  carry  salts  to  them.  It  therefore 
holds  that  the  purer  the  water  ingested,  the  greater  will  be  its  power 
of  absorption.  Water  free  from  mineral  salts  possesses  great  power  of 
absorption,  and  conversely  a  water  surcharged  with  mineral  salts  not 
only  fails  to  absorb  salts  from  the  tissues  but  may  actually  add  to  these 
salts.  Lime  salts  in  drinking  water  account  to  ^  degree  for  the  calcareous 
deposits  found  within  the  body,  which  inhibit  the  functions  of  the  blood- 
vessels and  the  organs  they  supply.  A  good  filter,  kept  clean,  will 
eliminate  microorganisms  from  the  water,  but  will  not  remove  the 
soluble  mineral  salts.  For  this  reason  distilled  water  becomes  the 
safest  and  best  of  drinking  waters. 

The  quantity  of  water  which  an  individual  in  good  health  should 
drink  depends  upon  the  body  weight,  the  activity  of  the  individual, 
and  the  temperature.  The  average  quantity  is  one  or  two  quarts  a 
day.  No  large  quantity  should  be  taken  with  the  meals  because  the 
secretions  of  the  stomach  become  diluted,  thereby  interfering  with 
digestion.    Water  should  be  drunk  freely  between  meals,  at  bedtime. 


HOT-AIR   TREATMENT  209 

and  upon  rising  in  the  morning.  Hot  water  is  an  aid  to  digestion  when 
taken  before  meals.  Cold  water  retards  digestion,  and  should  never 
be  taken  immediately  before,  during,  or  shortly  after  the  ingestion  of 
food. 

HOT-AIR  TREATMENT 

Physiological  Action  ;  Technic 

Indications  and  Contraindications  i 

The  author  has  had  but  a  limited  experience  in  the  use  of  hot  air  as 
a  remedial  agent  and  the  following  description  is  largelj^  based  upon  the 
experience  of  others. 

Physiological  Action. — ^An  active  hyperemia  is  produced.  With  a 
properly  applied  apparatus  this  action  is  not  confined  to  the  superficial 
bloodvessels  but  extends  to  the  deeper  structures.  At  the  beginning 
of  the  application,  when  the  temperature  is  high,  there  is  a  temporary 
contraction  of  the  bloodvessels  which  is  soon  followed  by  dilatation. 
According  to  Bier  this  arterial  hyperemia  provides  nourishment  for 
the  tissues,  favors  the  carrying  away  of  waste  stuffs,  and  stimulates  the 
regenerative  functions  of  the  tissues  to  a  degree  that  will  fortify  the 
tissues  against  the  invasion  of  microorganisms. 

Indications  and  Contra-indications. — Pregnancy  is  an  absolute  contra- 
indication to  the  application  of  heat  to  the  degree  required  to  obtain 
a  physiological  reaction.  Fever  is  also  said  to  be  a  contra-indication 
and  so  are  advanced  affections  of  the  lungs  and  incompetent  heart 
action. 

The  method  is  recommended  for  all  chronic  non-suppurative  inflam- 
matory exudates.  The  application  of  hot  air  is  also  recommended  in 
chronic  metritis  and  lactation  atrophy  of  the  uterus,  especially  when 
associated  with  edema. 

The  very  nature  of  these  lesions  suggests  the  limitations  of  this  form 
of  treatment.  Little  can  be  expected  from  any  remedy  in  the  manage- 
ment of  such  lesions. 

Hot-air  therapy  is  effective  not  so  much  in  the  correction  of  morbid 
anatomical  conditions  as  in  bringing  about  relief  from  pain  associated 
with  chronic  inflammatory  lesions.  This  relief  may  persist  for  many 
hours  after  application,  and  by  repeated  applications  the  pain  becomes 
less  in  frequency  and  in  severity.  The  relief  from  pain  is  particularly 
observed  when  an  edematous  infiltration  is  a  contributing  factor. 

Technic. — The  application  of  hot  air  to  the  vagina  is  impracticable. 
To  obtain  the  required  degree  of  heat  would  cause  pain  and  a  superficial 
inflammatory  reaction. 

The  method  is  therefore  confined  to  the  skin  surface  of  the  abdomen 
and  pelvis.  Before  proceeding  with  the  treatment  all  contra-indications 
must  be  excluded.  The  duration  of  the  treatment  should  not  exceed 
twenty  minutes  in  the  beginning  and  may  be  gradually  increased  to  an 
hour.  A^TLen  there  is  a  tendency  to  faintness  a  cold  cloth  may  be  placed 
on  the  head. 
14 


210 


NON-OPERATIVE  METHODS  OF  TREATMENT 


After  the  treatment  rest  in  bed  for  at  least  a  half-hour  should  be 
enjoined.  The  frequency  with  which  the  treatments  are  repeated  will 
be  governed  by  the  individual  case. 

The  degree  of  heat  should  at  first  not  exceed  200°  F.,  and  later  it 
may  gradually  be  raised  to  250°  F.  The  temperature  and  pulse  should 
be  taken  at  intervals  during  the  application,  and  a  physical  examination 
of  the  affected  area  should  be  made  to  ascertain  the  effects  of  the 
treatment  and  to  detect  any  existing  complications  "at  the  earliest 
possible  time.  The  treatment  may  be  combined  with  massage  and 
pressure  therapy  with  good  results. 

The  author  has  adopted  the  electric  heater  of  Gellhorn  (Fig.  95)  with 
gratifying  results. 


Application  of  dry  heat  (electric). 


HOT  PACK 


One  of  the  most  effective  means  of  quieting  a  nervous  patient  is  to 
wrap  the  body  in  a  sheet  wrung  out  in  water  at  a  temperature  of  50° 
to  70°  F.  Several  woollen  blankets  are  then  wrapped  snugly  about  the 
body.  In  a  few  minutes  the  body  will  begin  to  perspire  freely  and  often 
the  patient  falls  into  a  quiet  sleep.  This  bath  has  been  found  of  great 
value  in  treating  maniacal  patients. 


TAMPONS  211 

COUNTER-IRRITATION 


Cantharides  Plaster 
Mustard  Plaster 


In  pelvic  inflammation  considerable  relief  from  pain  may  result 
from  the  application  of  counter-irritants  over  the  seat  of  pain.  It  is 
of  interest  to  note  that  Morris  has  called  attention  to  the  two  points 
of  tenderness  located  over  the  lumbar  ganglia,  about  one  inch  below 
and  to  either  side  of  the  umbilicus.  Pressure  over  these  points  in  the 
presence  of  a  chronic  pelvic  inflammation  will  elicit  more  or  less  tender- 
ness. If  these  areas  of  tenderness  are  painted  with  tincture  of  iodine, 
or  if  a  mustard  or  cantharides  plaster  is  applied,  much  relief  may  be 
afforded.  In  this  manner  much  of  the  pain  incident  to  the  menstrual 
period  in  the  course  of  a  pelvic  inflammation  may  be  controlled. 

Cantharides  Plaster. — In  applying  a  cantharides  plaster  the  skin 
is  first  cleansed  with  soap  and  water,  then  dried,  and  smeared  with 
vaseline.  Over  an  area  about  two  inches  in  diameter  on  either  side  is 
applied  a  cantharides  plaster.  This  is  held  in  place  by  two  cross-strips 
of  adhesive  plaster  for  six  to  eight  hours  until  blisters  appear.  The 
plaster  is  then  removed,  the  blisters  opened  in  a  cleanly  manner,  and 
a  zinc  ointment  applied  to  the  blistered  surface.  Over  this  is  placed  a 
pad  of  sterile  gauze,  held  in  place  by  adhesive  straps.  The  surface 
is  dressed  daily  until  all  signs  of  irritation  have  disappeared.  Collodium 
cantharidations  (60  per  cent.)  may  be  applied  with  a  camel's-hair 
brush. 

Mustard  Plaster. — To  prepare  a  mustard  plaster  use  half  and  half 
black  mustard  and  flaxseed  meal  or  flour.  If  white  mustard  is  used 
it  should  be  used  in  the  proportion  of  three  of  mustard  to  one  of  flour 
or  flaxseed  meal.  These  are  applied  hot  for  a  half  hour.  If  a  longer 
application  is  desired  the  proportion  of  mustard  is  lessened. 


TAMPONS 

No  one  form  of  topical  treatments  in  diseases  of  women  is  so  generally 
employed  as  tampons.  When  applied  intelligently  they  are  of  great 
value,  but  in  so  doing  there  must  be  a  very  clear  conception  of  their 
indications  and  of  the  manner  of  their  application,  otherwise  they 
are  productive  of  no  good  and  may  do  positive  harm. 

Indications. — The  indications  for  tamponade  of  the  vagina  are: 

1.  Hemorrhage. 

2.  Pelvic  inflammations  and  congestion. 

3.  Drainage. 

4.  Protection  against  infection. 

5.  Uterine  support. 

Hemorrhage. — For  the  immediate  control  of  hemorrhage  from  the 
uterus  and  vagina,  resort  may  be  had  to  the  vaginal  tampon.     This 


212  NON-OPERATIVE  METHODS  OF   TREATMENT 

measure  may  suffice  for  temporary  or  permanent  control  of  the  bleeding, 
depending  upon  the  seat  of  the  hemorrhage,  its  cause,  and  its  severity. 
When  the  bleeding  comes  from  large  vessels  in  the  cervix  or  vagina,  or 
when  the  hemorrhage  comes  from  within  the  uterus  and  is  severe, 
failure  is  likely  to  ensue.  However,  until  more  effective  means  can  be 
employed,  tightly  packed  vaginal  tampons  should  be  resorted  to. 

Form  of  Tamponade. — Vaginal  Tampons. — Tampons  when  tightly 
packed  in  the  vagina  will  control  bleeding  from  the  vaginal  walls, 
and  will  be  effective  in  moderate  hemorrhages  from  the  cervix  and 
cavity  of  the  uterus. 

Whenever  a  bleeding  vessel  can  be  isolated  it  should  be  secured  by  a 
ligature  or  transfixed  by  a  suture. 

Intra-uterine  Tampons. — Xo  other  method  is  so  effective  in  the 
control  of  bleeding  from  the  uterus  into  the  uterine  cavity.  It  may 
be  stated,  as  a  general  rule,  that  the  uterus  should  be  tamponed  after 
all  intra-uterine  operations  whenever  there  is  a  possibility  of  post- 
operative hemorrhage.  Curettement  for  conditions  such  as  endometritis 
is  not  included  in  this  category. 

Technic. — ^The  best  material  for  intra-uterine  and  vaginal  tampons 
used  for  the  purpose  of  controlling  hemorrhage  is  sterile,  plain,  or  iodo- 
form gauze.  Strips  two  to  four  inches  in  width,  several  plies  in  thickness 
and  of  sufficient  length  to  pack  the  uterus  and  vagina  tightly,  are 
preferred. 

When  the  uterine  cavity  is  to  be  packed  a  thorough  sterilization  of 
the  vulva  and  vagina  should  precede  the  packing.  The  patient  is 
placed  crosswise  of  the  bed  in  the  dorsal  position  and  every  precaution 
is  taken  to  protect  the  gauze  from  contamination. 

A  bivalve  speculum  is  introduced  through  which  the  cervix  is  grasped 
by  a  tenaculum.  The  end  of  the  gauze  strip  is  then  conveyed  to  the 
fundus  of  the  uterus  by  means  of  a  dressing  forceps  or  sound.  This 
must  be  done  with  caution  for  fear  of  perforating  the  uterine  wall.  The 
cavity  of  the  uterus  is  gently  but  firmly  packed  from  above  downward 
until  the  entire  cavity,  including  that  of  the  cervix,  is  filled.  ]More 
than  this  the  vagina  should  be  firmly  packed  and  a  T-binder  adjusted 
over  a  sterile  vulvar  pad.  When  the  vagina  alone  is  to  be  packed  for 
the  control  of  hemorrhage  the  same  aseptic  precautions  must  be  exer- 
cised, and  the  packing  should  be  done  through  a  vaginal  speculum. 

The  gauze,  as  a  rule,  should  be  removed  by  the  end  of  forty-eight 
hours,  and  if  the  hemorrhage  still  continues  fresh  gauze  may  be  inserted. 

Inflammation  and  Congestion. — Tampons  have  a  therapeutic  value 
in  all  stages  of  pelvic  inflammation  and  congestion.  As  a  vehicle  for 
the  introduction  of  medicaments  the  vaginal  tampon  has  a  large  range 
of  application.  It  provides  the  only  practical  and  effective  means  of 
applying  remedies  to  the  vaginal  walls  and  overlying  structures. 

But  few  remedies  have  been  accepted  as  being  of  very  special  thera- 
peutic value;  such  are  ichthyol,  formalin,  iodine,  mercurial  ointments, 
gylcerin  and  certain  combinations  of  glycerin,  notably  boroglycerin 
and  borolyptol.     Glycerin  and  ichthyol  are  the  most  generally  used 


TAMPONS 


213 


Fig.  96 


of  these  remedies.  Glycerin  withdraws  serum  from  the  tissues,  and 
in  this  manner  the  tissues  of  the  pelvis  are  depleted;  connective-tissue 
spaces  are  emptied  of  serous  exudates,  serous  elements  are  withdrawn 
from  pus  cavities  and  the  engorged  lymph  and  bloodvessels  are  relieved. 
To  accomplish  this  large  quantities  of  glycerin  must  be  used.  The 
vagina  should  be  loosely  packed  with  tampons  of  sterile  cotton  or  gauze 
in  glycerin.  The  time  required  for  the  application  of  the  glycerin 
may  be  stated  at  six  to  eight  hours.  They  should  then  be  removed 
lest  they  become  a  source  of  irritation.  The  amount  of  serum  that  is 
extracted  from  the  tissues  in  this  way  is  often  astonishing. 

As  a  valuable  adjunct  to  glycerin,  ichthyol  may  be  added  in  the 
proportion  of  seven  part  of  ichthyol  to  ninety-three  parts  of  glycerin. 
It  is  claimed  for  ichthyol  that  it  is  somewhat  antiseptic  and  analgesic 
and  an  absorbent  of  cellular  elements.  These  properties  in  conjunction 
with  the  glycerin,  which  only  withdraws 
the  watery  elements,  makes  the  combi- 
nation most  effective.  Ichthyol  is  gen- 
erally accepted  as  a  valuable  remedy  in 
the  treatment  of  pelvic  inflammations, 
and  especially  when  combined  with  gly- 
cerin in  the  proportions  given.  It  is 
indorsed  almost  uniformly  by  practical 
workers  in  the  field  of  gynecology.  Exu- 
dates are  absorbed  by  the  liberal  appli- 
cation of  ichthyol  and  glycerin — this 
applies  to  serous,  purulent,  and  cellular 
exudates  alike.  Under  this  treatment 
the  author  has  seen  large  pelvic  exudates 
disappear  and  pus  accumulation  absorb. 
In  one  case  of  bilateral  pyosalpinx  the 
tubes  were  not  only  reduced  to  their 
normal  size,but  pregnancy  followed  in  the 
course  of  a  vear  and  terminated  unevent- 
fully. 

The  uterus  and  appendages,  enlarged  from  congestion,  are  reduced  in 
size  and  rendered  less  sensitive.  Excessive  bloody  and  leucorrheal  dis- 
charges are  lessened  by  depleting  the  engorged  lymph  and  bloodvessels. 
Menstruation  is  rendered  less  painful  by  relieving  the  congestion.  It 
is  therefore  evident  that  local  depleting  treatment  by  means  of  tampons 
is  worthy  of  the  serious  consideration  of  surgeons.  In  not  a  few  cases 
these  treatments,  combined  with  prolonged  hot  douches,  and  the 
regulation  of  the  bowels,  diet,  and  exercise,  will  effect  a  cure  that  is 
impossible  by  other  means. 

They  are  valuable  adjuncts  to  surgery  both  as  a  preliminary  measure 
and  as  a  postoperative  means  of  restoring  the  integrity  of  the  tissues. 
The  surgeon  is  seldom  justified  in  interfering  surgically  during  the 
acute  stage  of  a  pelvic  inflammation  unless  there  is  an  accumulation 
of  pus  that  can  be  drained  through  the  vagina.      By  first  depleting 


-c^y 


Vaginal  tampon  of  lambs'  wool. 


214  NON-OPERATIVE  METHODS  OF  TREATMENT 

the  tissues  the  acute  inflammatory  reaction  is  allayed,  exudates  are  ab- 
sorbed and  the  need  for  surgical  intervention  may  be  averted;  organs 
are  safeguarded  which  have  been  sacrificed  without  these  preliminary 
measures. 

Postoperative  exudates  in  and  about  the  genital  organs  demand 
consideration,  otherwise  the  results  will  be  disappointing.  Such 
exudates  may  be  made  to  disappear  by  the  treatment  outlined.  To 
remove  a  diseased  endometrium  and  leave  a  congested  uterus  affords 
little  or  no  permanent  relief;  a  healthy  endometrium  cannot  be 
expected  to  form,  and  the  congested  uterus  will  remain  a  disturbing 
element;  hence  the  value  of  depleting  treatment  as  a  postoperative 
measure. 

The  author  cannot  agree  with  Dudley,  who  says  that  the  therapeutic 
value  of  medicated  tampons  is  overestimated.  While  it  is  true  that 
they  are  too  often  misapplied,  it  is  even  more  true  that  their  therapeutic 
value  is  not  fully  appreciated.  The  former  statement  applies  particu- 
larly to  the  general  practitioner,  the  latter  to  the  general  surgeon. 

For  subacute  and  chronic  vaginitis  the  vagina  may  be  loosely  packed 
with  strips  of  sterile  gauze  saturated  with  a  solution  of  formalin,  1  part ; 
glycerin,  400  parts;  water,  2000  parts.  For  specific  ulcers  of  the 
cervix  and  vagina,  tampons  of  sterile  cotton  or  gauze  may  be  smeared 
with  mercurial  ointment. 

Duration  of  Application. — No  tampon  should  be  left  in  the  vagina 
longer  than  twenty-four  hours.  The  accumulated  secretions  of  the 
uterus  become  a  source  of  irritation,  hence  the  tampons  should  be 
removed  within  twenty-four  hours  and  a  vaginal  douche  given. 

Frequency  of  Application. — No  set  rule  can  be  established  for  the 
frequency  of  application  of  uterine  and  vaginal  tampons.  Each  case 
must  be  a  law  unto  itself. 

When  tampons  are  used  for  depleting  purposes  they  should  be 
inserted  at  least  every  other  day.  During  the  acute  stage  of  a  pelvic 
inflammation  they  should  be  applied  daily.  The  patient  should  remain 
in  bed  while  the  tampons  are  in  place,  otherwise  much  of  the  solution 
will  be  lost.  For  this  reason  such  treatments  given  in  the  office  are 
of  little  value. 

Twenty-four  to  forty-eight  hours  is  the  limit  of  time  for  the  appli- 
cation of  intra-uterine  tampons,  and  it  is  seldom  advisable  to  repeat 
the  application.  There  is  always  the  danger  of  conveying  infection 
to  the  uterus  by  tamponing  the  uterine  cavity,  and  for  this  reason  their 
application  should  be  as  limited  as  possible. 

For  the  control  of  hemorrhage,  vaginal  and  intra-uterine  tampons 
are  allowed  to  remain  no  longer  than  is  demanded  for  fear  that  the 
accumulated  blood  may  undergo  decomposition  and  infection.  When 
removed  a  vaginal  douche  should  be  given. 

Drainage. — Some  operators  drain  the  uterus  with  a  strip  of  sterile 
gauze  after  curettage.  To  the  author  this  procedure  has  never  seemed 
necessary  or  advisable,  because  the  uterus,  in  itself,  constitutes  an 
ideal  drain. 


PELVIC  MASSAGE 


215 


Protection  against  Infection. — After  all  intra-uterine  operations  it 
is  advisable  to  pack  the  vagina  with  sterile  or  iodoform  gauze  as  a 
precaution  against  possible  infection  of  the  wound  within  the  uterus. 
Such  dressings  should  not  be  left  longer  than  forty-eight  hours. 


Fig.  97 


Insertion  of  a  tampon  ol'  lanil 


Support  to  the  Uterus. — Vaginal  tampons  of  sterile  lambs'  wool 
are  of  service  in  uterine  displacements  when  for  any  reason  a  pessary 
cannot  be  worn,  and  operative  interference  is  not  permissible.  For 
example,  the  vagina  may  not  tolerate  a  pessary,  or  a  uterus  and  its 
appendages  may  be  so  tender  that  they  do  not  permit  the  w^earing 
of  a  pessary  because  of  pain  and  the  likelihood  of  exciting  an  acute 
inflammatory  reaction.  Tampons  for  this  purpose  are  only  temporary 
expedients,  and  should  soon  be  replaced  by  the  pessary  or  by  operative 
intervention. 


PELVIC  MASSAGE 


Physiological  Action 
Indications 


contra-indications 
Technic 


This  therapeutic  measure  has  found  little  favor  in  America,  although 
in  Sweden,  from  whence  it  emanated,  and  in  Germany  and  France, 


216  NON-OPERATIVE  METHODS  OF  TREATMENT 

it  is  much  practised.  The  successful  application  of  massage  to  pelvic 
disorders  implies  an  accurate  diagnosis.  The  indications  are  limited 
to  but  a  few  lesions  in  the  pelvis,  and  the  pathological  conditions 
which  preclude  its  application  must  be  recognized  if  dangers  are  to  be 
averted. 

Physiological  Action. — The  circulation  in  the  blood  and  lymph  vessels 
is  accelerated.  This  increases  the  nutrition  of  the  tissues  on  the  one 
hand  and  favors  the  absorption  of  exudates  on  the  other.  Furthermore, 
the  involuntary  muscle  fibers  of  the  viscera  are  made  to  contract,  which 
in  turn  favors  the  circulation  in  these  organs. 

Indications. — Chronic  Non-suppurating  Pelvic  Inflammations. — When 
they  involve  the  uterus,  its  appendages,  the  pelvic  cellular  tissue  and 
peritoneum,  well-directed  massage  is  a  valuable  adjunct  to  the  more 
generally  employed  methods  of  treatment.  When  the  uterus  and  its 
appendages  are  displaced  and  immobilized  to  a  greater  or  less  degree 
by  adhesions  the  offending  bands  may  be  stretched  or  severed,  thus 
providing  for  the  replacement  of  the  viscera.  Inflammatory  exudates 
in  and  about  the  organs  of  the  pelvis  are  made  to  disappear  by 
stimulating  the  lymphatic  circulation  through  a  systematic  and  oft- 
repeated  system  of  massage. 

Contracted  Uterine  Ligaments. — Contracted  uterine  ligaments,  result- 
ing from  an  inflammatory  infiltration,  may  be  stretched  and  the 
inflammatory  exudate  absorbed  by  intelligent  and  persistent  massage. 
By  so  doing  the  uterus  and  its  appendages  may  be  placed  in  their 
normal  position  and  retained  either  by  the  wearing  of  a  suitable  pessary 
or  by  some  operative  procedure. 

Atony  of  the  Uterine  Supports. — ^Atony  of  the  uterine  supports  may  be 
corrected  when  not  of  long  standing,  but  when  the  muscular  fibers  and 
connective  tissue  which  are  incorporated  in  the  uterine  supports  have 
lost  their  power  of  retraction  and  contraction  the  results  of  massage 
are  not  encouraging,  and  will  usually  be  disappointing. 

Incarceration  of  the  Pregnant  and  Non-pregnant  Uterus  and  of  Tumor 
Formations. — These  may  be  corrected  by  means  of  massage.  An 
anesthetic  is  usually  required. 

Contra-indications. — Certain  conditions  may  exist  in  the  pelvis 
which  render  pelvic  massage  both  useless  and  dangerous.  It  is,  there- 
fore, imperative  that  such  conditions  be  excluded  before  resorting  to 
massage. 

Acute  Pelvic  Inflammations. — Massage  is  contraindicated  not  only  be- 
cause of  the  pain  occasioned  by  the  manipulations,  but  more  so  because 
of  the  possibility  of  extending  the  infection.  An  infection  confined 
to  the  uterus  may  be  made  to  extend  to  the  tubes;  when  in  the  tubes 
it  may  be  stripped  from  the  fimbriated  end  into  the  peritoneal  cavity; 
when  walled  off  in  the  peritoneal  cavity  by  adherent  coils  of  bowel 
and  omentum  the  pus  may  be  liberated  and  invade  the  free  peritoneal 
cavity,  and  finally  a  virulent  infection  may  be  passed  on  by  way  of 
the  blood  and  lymph  streams  to  remote  parts  of  the  body.  There  is 
a  special  danger  in  massage  of  an  infected  puerperal  uterus,  filled  as  it 


PELVIC  MASSAGE  217 

is  with  septic  thrombi.  These  thrombi  may  be  dislodged  and  con- 
veyed to  the  lungs,  where  they  cause  one  of  the  most  fatal  of  lesions — 
i.  e.,  pulmonary  embolism. 

The  rule  should  be  to  avoid  all  unnecessary  ma7iipulations  during  the 
acute  stage  of  a  pelvic  inflammation. 

Malignancy. — Unquestionably  malignant  growths  are  made  more 
active  and  are  disseminated  by  massage.  Inasmuch  as  no  possible 
good  can  come  from  massage  in  these  cases,  and  much  harm  may 
ensue,  the  practice  is  condemned. 

Tuberculosis  of  the  Pelvic  Organs. — This  offers  the  same  objections 
to  massage  as  malignancy. 

Pregnancy. — Pregnancy,  both  intra-uterine  and  extra-uterine,  is  to 
be  classed  with  the  contra-indications  to  massage.  An  exception  may 
be  made  when  the  pregnant  uterus  is  adherent  or  incarcerated.  In 
such  cases  gentle  manipulations  may  succeed  in  replacing  the  uterus, 
and  in  making  the  uterus  freely  movable,  without  interrupting  preg- 
nancy. When  there  is  a  possibility  of  tubal  pregnancy  all  manipulation 
must  be  avoided  for  fear  of  rupturing  the  tube. 

Fig.  98 


Combined  vaginal  and  abdominal  massage.     Patient  lying  on  couch.     All  constriction  about  the 
waist  line  removed.    Two  fingers  of  the  right  hand  within  the  vagina.    Left  hand  on  the  abdomen. 

Phlebitis  and  Thrombosis. — Phlebitis  and  thrombosis  of  the  pelvic  and 
femoral  veins  contra-indicate  massage  for  fear  of  dislodging  thrombi, 
an  event  which  may  culminate  disastrously  through  the  development 
of  pulmonary  embolism. 

Technic. — Before  proceeding  with  massage  of  the  pelvis  the  rectum 
and  bladder  should  be  emptied,  and  the  clothing  so  arranged  as  to 
eliminate  all  constriction  of  the  waist,  and  to  avoid  any  embarrass- 


218 


NON-OPERATIVE  METHODS  OF  TREATMENT 


ment  to  the  manipulations  of  the  operator.  The  patient  should  lie 
upon  a  low-firm  couch  with  the  hips  brought  to  the  end  of  the  couch,  the 
legs  flexed  upon  the  thighs  and  the  feet  resting  upon  a  chair  placed 
at  the  end  of  the  couch. 

The  operator  sits  at  one  side  of  the  couch,  passes  his  forearm  under 
the  corresponding  knee  of  the  patient,  and  introduces  the  index  and 
middle  fingers  into  the  vagina  to  the  vaginal  vault  at  the  point  to 
which  the  massage  is  to  be  directed.  No  manipulations  are  performed 
by  the  fingers  within  the  vagina;  they  are  introduced  for  the  purpose 
of  supporting  and  steadying  the  structures  to  be  massaged.  The 
opposite  hand,  placed  upon  the  hypogastrium,  performs  rotary  move- 
ments, very  gently  at  first  and  increasing  in  speed  and  pressure  as  the 


Abdominal  massage. 


abdominal  muscles  relax.  There  should  be  short  intervals  of  rest  and 
the  whole  sitting  should  not  consume  more  than  ten  minutes,  and 
shoidd  be  repeated  daily. 

Massage  of  the  uterus  is  carried  out  by  bringing  the  uterus  as  far 
forward  as  possible  by  the  combined  efforts  of  the  fingers  within  the 
vagina  and  those  of  the  hand  placed  upon  the  abdomen.  The  move- 
ments are  directed  by  the  hand  upon  the  abdomen  to  the  posterior 
wall  of  the  uterus,  while  the  fingers  within  the  vagina  press  upward 
and  forward,  and  upward  and  backward  against  the  cervix. 

The  tubes  are  massaged  from  their  outer  extremity  to  the  uterine 
horn.  The  manipulations  of  the  ovaries  are  similar  to  those  of  the 
uterus. 

In  massaging  inflammatory  exudates  the  operator  begins  at  the 
periphery  of  the  mass,  passing  around  the  circumference  and  gradually 
approaching  the  centre. 


PELVIC  MASSAGE  219 

Stretching  and  breaking  of  adhesions  binding  the  uterus  and  its 
appendages  should  be  done  without  force.  Undue  force  in  breaking 
up  adhesions,  as  advised  by  Schultze,  is  to  be  discountenanced  because 
of  the  danger  of  hemorrhage,  of  tearing  into  an  adherent  bowel  and 
of  the  liability  of  the  uterus  to  adhere  again  and  to  resume  a  faulty; 
position. 

The  gradual  breaking  and  stretching  of  adhesions  is  conducted  by 
the  index  and  middle  fingers  of  the  left  hand  within  the  vagina,  directed 
to  the  site  of  the  adhesions.  The  fingers  of  the  right  hand  placed 
upon  the  abdomen  are  made  to  approximate  the  fingers  in  the  vagina  by 
a  series  of  rotary  movements  which,  when  gently  performed,  will  cause 
the  abdominal  walls  to  relax  and  permit  of  deep  pressure.  No  great 
pain  must  be  caused,  otherwise  the  contractions  of  the  abdominal 
muscles  will  embarrass  the  procedure.  The  manipulations  of  the 
abdominal  hands  are  at  times  reinforced  by  the  fingers  within  the 
vagina,  the  pressure  being  directed  on  the  adherent  organ  in  such  a 
manner  as  to  put  the  adhesions  on  the  stretch. 

Xo  rule  can  be  formulated  to  govern  the  amount  of  pressure  to  be 
exerted,  or  to  regulate  the  time  to  be  consumed  in  breaking  up  the 
adhesions.     The  operator  must  exercise  needed  caution. 

The  replacement  of  a  malposed  uterus  by  massage  deserves  careful 
consideration  because  the  procedure  is  in  common  practice  throughout 
the  medical  world.  Little  or  no  success  has  resulted  from  the  application 
of  massage  in  pathological  anteflexion.  The  method  consists  in  pressing 
backward  upon  the  cervix  with  the  vaginal  finger  and  at  the  same  time, 
backward,  intermittent  pressure  is  made  with  the  fingers  of  the  other 
hand  upon  the  fundus. 

In  the  effort  to  correct  a  lateral  position  (lateroversion,  lateroflexion, 
lateroposition),  pressure  is  directed  upon  the  side  of  the  uterus.  When 
the  broad  ligament  is  infiltrated  it  must  be  massaged  independently 
of  the  uterus  to  favor  the  absorption  of  the  inflammatory  exudate. 

Retrodisplacements  of  the  uterus  are  particularly  favorable  to 
correction  by  pelvic  manipulations.  The  index  and  middle  flngers  of 
the  left  hand  make  pressure  upon  the  posterior  wall  of  the  uterus;  the 
pressure  is  steady,  firm,  and  in  an  upward  direction.  Counter-pressure 
is  made  over  the  hypogastrium  with  the  other  hand  in  the  eft'ort  to 
grasp  the  fundus  of  the  uterus.  Gradually  the  abdominal  fingers  are 
brought  behind  the  fundus,  when  by  the  combined  efl^orts  of  the  fingers 
over  the  abdomen  and  in  the  vagina,  the  uterus  is  drawn  to  a  vertical 
position. 

To  bring  the  uterus  more  nearly  to  the  normal  position,  that  of 
anteversion  and  anteflexion,  the  fingers  within  the  vagina  are  shifted 
to  the  front  of  the  cervix,  and  backward  pressure  is  made  upon  the 
vaginal  portion  of  the  cervix,  while  forward  traction  is  made  upon  the 
fundus  by  the  fingers  on  the  abdomen.  When  the  uterus  is  righted  in 
its  position,  a  Hodge-Smith  pessary  is  inserted  to  maintain  the  uterus 
in  its  normal  position. 

As  an  aid  to  the  hands  in  replacing  the  uterus,  Olshausen  recommends 


220  NON-OPERATIVE  METHODS  OF  TREATMENT 

the  uterine  sound.  In  the  hands  of  the  inexperienced  this  instrument 
is  dangerous.  In  the  author's  judgment  it  is  better  to  dispense  with  it 
altogether  in  view  of  the  Habihty  of  puncturing  the  uterus,  even  in 
the  hands  of  the  most  careful  and  experienced.  When  the  uterus  is 
displaced  backward  and  is  freely  movable  it  may  be  possible  to  effect 
a  replacement  by  placing  the  patient  in  the  knee-chest  position  and 
introducing  a  Sims  speculum  into  the  vagina.  The  air  will  balloon 
out  the  vagina,  the  intestines  will  fall  away  from  the  uterus  and  permit 
it  to  fall  forward  upon  the  anterior  abdominal  wall. 

As  an  aid  to  the  replacement  of  the  uterus,  traction  may  be  made 
upon  the  cervix  by  a  vulsellum  forceps.  When  the  uterus  lies  far 
back  and  upon  the  rectum,  pressure  may  be  best  directed  upon  the 
fundus  by  the  index  finger  inserted  high  in  the  rectum. 

In  atony  of  the  uterus  resulting  in  uterine  hemorrhage,  gentle  massage 
will  cause  the  uterus  to  contract;  in  this  manner  the  caliber  of  the 
bloodvessels  is  lessened  and  the  hemorrhage  checked. 

It  is  said  that  massage  of  the  posterior  wall  of  the  uterus  at  a  point 
near  the  internal  os  will  most  effectually  stimulate  the  contractions 
of  the  uterus. 

Abdominal  Massage.^ — ^Abdominal  massage  may  be  beneficial  in 
conjunction  with  pelvic  massage.  This  applies  particularly  to  those 
cases  in  which  constipation  is  a  disturbing  factor,  or  when  there  is  a 
general  or  localized  accumulation  of  adipose  tissue  in  the  abdominal 
wall,  when  the  muscular  development  of  the  abdominal  wall  is  poor 
and  the  recti  are  separated,  when  there  is  hyperesthesia  of  the  abdomi- 
nal wall,  and,  finally,  when  there  are  old  inflammatory  exudates  and 
adhesions  in  relation  to  the  abdominal  wall. 

Technic. — The  operation  should  not  be  performed  in  less  than  two  hours 
after  eating.  The  patient  lies  upon  a  firm  couch  with  legs  flexed  upon 
the  thighs  and  the  thighs  upon  the  abdomen,  the  mouth  open.  The 
index,  middle,  and  ring  fingers  of  the  left  hand  are  laid  upon  the  abdomen. 
The  same  fingers  of  the  right  hand  make  pressure  upon  them  as  seen 
in  figure  98,  and  direct  the  fingers  of  the  left  hand  in  performing  rotary 
movements  as  outlined  in  the  spiral  lines  upon  the  abdomen  in  Fig.  99. 
The  pressure  is  at  first  light,  and  after  the  abdominal  walls  are  relaxed, 
it  is  increased  sufficiently  to  affect  the  underlying  visceral  structures. 

PRESSURE  THERAPY 

Indications 
Technic 

The  so-called  "absorption  cure"  as  applied  to  certain  chronic  inflam- 
matory diseases  of  the  pelvis  was  introduced  by  W.  A.  Freund.  The 
absorption  of  pelvic  exudates  is  facilitated  by  means  of  pressure 
applied  directly  to  the  exudate.  A  bag  containing  several  pounds  of 
shot  is  placed  over  the  abdomen  and  a  rubber  condom,  filled  with  800 
to  1000  grams  of  shot,  is  inserted  into  the  vagina  and  impinges  upon 
the  exudate.    Freund  reports  excellent  results  in  the  treatment  of  fixed 


PRESSURE  THERAPY  221 

retroverted  uteri,  salpingitis,  acquired  and  congenital  narrowing  of 
the  vagina. 

Other  methods  have  been  introduced,  based  upon  the  same  general 
principle.  Chrobak  practised  traction  massage  by  applying  a  weight 
of  one  to  one  and  a  half  kilograms  to  the  cervix,  making  traction  for 
one-half  to  ten  hours.  Saenger  advised  interrupted  traction  on  the  cervix. 
Pincus  used  a  shot-bag  over  the  abdomen  and  an  air  pessary  or  air- 
bag  in  the  vagina.  This  method  is  based  upon  the  theory  that  the 
pressure  from  without  was  of  prime  importance,  and  the  air-bag  or 
pessary  within  the  vagina  was  merely  to  support  the  uterus.  Freund, 
however,  laid  greater  stress  upon  intravaginal  pressure. 

An  important  modification  of  Freund's  method  was  introduced  by 
Joseph  Halban.  In  place  of  a  rubber  condom  filled  with  shot,  he  used 
a  Carl  Braun's  colpeurynter  filled  with  quicksilver.  This  modification 
has  a  twofold  advantage,  in  that  it  is  easy  of  application,  and  a  greater 
and  more  evenly  applied  pressure  can  be  obtained  with  the  same  bulk 
in  the  vagina.  A  pressure  of  1500  grams  of  quicksilver  is  possible 
by  this  method,  a  pressure  that  is  altogetlier  impossible  in  Freund's 
method.  Then,  too,  quicksilver  in  the  colpeurynter  moulds  itself  more 
perfectly  to  the  exudate  than  is  possible  for  a  bag  of  shot. 

Indications. — Pelvic  Cellulitis. — This  treatment  is  particularly  eft'ective 
by  reason  of  the  location  of  the  lesion.  The  exudate  is  found  most 
frequently  in  the  cul-de-sac  of  Douglas,  or  in  the  base  of  the  broad 
ligament,  where  direct  pressure  can  be  exerted.  The  whole  vault  of  the 
vagina  may  be  surrounded  by  a  stone-like  mass,  suggestive  of  malignant 
infiltration;  the  uterus  and  adnexa  may  be  lost  in  the  mass,  and  yet 
after  two  or  three  treatments  the  size  of  the  mass  may  be  so  decreased 
that  the  uterus  and  its  appendages  can  be  clearly  outlined.  The  rapidity 
with  which  these  results  are  obtained  can  only  be  accounted  for  on  the 
supposition  that  the  bulk  of  the  mass  is  largely  composed  of  serous 
exudate  which  rapidly  disappears  on  pressure,  leaving  a  greatly  reduced 
cellular  exudate.  It  has  been  frequently  observed  that  the  subjective 
symptoms  do  not  always  disappear  in  proportion  to  the  decrease  in 
size  of  the  exudates.  In  the  treatment  of  retro-uterine  exudates, 
Halban  tried  introducing  the  colpeurynter  into  the  rectum,  but  found 
this  method  impractical  because  of  pain,  and  of  the  more  direct 
pressure  upon  the  rectum  rather  than  upon  the  pelvic  exudate. 

Perimetritic  Exudates. — In  perimetritic  exudates  the  effect  of  pressure 
is  not  so  satisfactory  because  of  the  higher  location  of  the  exudate. 
When  the  adhesions  are  high  on  the  fundus  of  the  uterus  little  pressure 
can  be  directly  exerted.  Pelvic  massage  or  the  more  radical  operative 
procedures  are  preferred.  When  the  exudate  is  located  low  on  the 
pelvic  floor  the  adhesions  commonly  disappear  early  and  there  is  relief 
from  pain.  When  the  uterosacral  ligaments  are  involved  in  a  chronic 
inflammation  they  become  contracted  and  throw  the  uterine  body  for- 
ward. The  patients  complain  of  painful  coition,  and  a  similar  pain  is 
caused  by  the  drawing  forward  of  the  cervix,  though  the  uterus  itself 
and  its  appendages  are  not  sensitive  to  pressure.     A  colpeurynter  filled 


222  NON-OPERATIVE  METHODS  OF  TREATMENT 

with  quicksilver  placed  behind  the  cervix  will  so  stretch  the  uterosacral 
ligaments  as  to  give  most  satisfactory  results  in  correcting  the  con- 
traction of  the  ligaments  and  in  ^elie^dng  the  pain.  When  the  uterine 
appendages  are  involved,  the  results  of  pressure  therapy  depend  largely 
upon  the  position  of  the  diseased  appendages.  If  in  a  normal  position 
intravaginal  pressure  cannot  be  effectively  applied,  but  if  the  tubes 
and  ovaries  lie  low  in  the  pelvis,  as  is  often  the  case,  direct  pressure 
may  be  applied  with  telling  effect. 

It  is  impossible,  in  all  cases,  to  foresee  the  presence  of  a  virulent 
infection  which  may  lie  latent  in  the  adnexa.  Great  caution  must 
therefore  be  exercised  in  applying  such  energetic  treatment  for  fear 
of  exciting  an  acute  exacerbation  of  a  chronic  inflammation.  This  is 
particularly  true'  of  gonorrheal  infection.  It  is  well  known  that  the 
size  of  the  adnexal  tumors  is  not  proportionate  to  the  pain  caused,  and 
so  it  is  with  the  treatment,  the  inflammatory  exudate  may  be  greatly 
reduced  in  size  with  little  or  no  relief  from  pain;  on  the  other  hand,  the 
exudate  may  be  but  little  reduced  in  size  and  the  pain  wholly  disappear. 

Fixed  Retroverted  and  Retroflexed  Uteri. — It  is  in  the  replacement  of 
fixed  retroverted  and  retroflexed  uteri  that  pressure  therapy  gives 
the  most  brilliant  results.  In  Schauta's  clinic  it  is  now"  rarely  found 
necessary  to  anesthetize  a  patient  in  order  to  replace  a  fixed  retro- 
placed  uterus.  The  colpeurynter  placed  behind  the  cervix  crowds  the 
uterine  body  forward,  favors  the  stretching  and  absorption  of  adhesive 
bands,  and  at  the  same  time  the  posterior  vaginal  wall  is  put  upon  the 
stretch  and  tends  to  draw  the  uterus  forward. 

Incarcerated  Pregnant  Uterus. — The  Halban  method  has  been  lately 
advised  in  the  treatment  of  incarcerated  pregnant  uteri.  Halban 
reports  success  in  a  single  trial,  and  says  it  is  not  advisable  to  make 
more  than  two  or  three  efforts  at  replacement  by  this  method.  He  has 
given  30  to  40  treatments  in  a  single  case  and  observed  no  progress 
after  the  first  two  or  three  treatments.  Incarcerated  pelvic  tumors 
may  be  treated  by  the  same  method  if  located  low  in  the  pelvis. 

Pressure  therapy  is  not  recommended  as  a  substitute  for  massage  in 
all  cases.  There  are  cases  in  which  massage  is  preferable,  as  for  example 
in  adhesions  attached  to  the  fundus  of  the  uterus,  or  involving  normally 
placed  appendages;  but  in  the  majority  of  instances  the  Halban  pro- 
cedure is  more  convenient  of  application  and  the  results  are  more 
quickly  gained,  requiring  days  where  pelvic  massage  may  require 
weeks,  and  even  months. 

Technic. — In  applying  this  method  the  patient  is  placed  either  upon 
her  back  or  side;  on  her  back  if  the  exudate  lies  behind  the  uterus;  on 
the  corresponding  side  if  the  exudate  lies  to  the  side  of  the  uterus.  The 
colpeurynter  is  rolled  like  a  cigar,  smeared  with  vaseline,  and  introduced 
into  the  vagina  by  a  dressing  forceps.  It  is  placed  in  direct  contact 
with  the  exudate.  The  foot  of  the  bed  is  raised  and  additional  elevation 
gained  by  pillows  placed  under  the  hips.  The  bladder  and  rectum  must 
be  empty,  otherwise  some  discomfort  will  be  caused  when  the  bag  is 
filled.    The  colpeurynter  is  now  filled  with  quicksilver,  poured  through 


X-RAY   THERAPY  223 

a  funnel.  At  first  it  is  well  to  use  not  more  than  500  grams,  and  later 
to  increase  the  amount  to  1000  grams.  Were  the  patient  lying  on  a 
level  plane  the  pressure  would  be  largely  applied  to  the  rectum,  while 
with  the  hips  elevated  the  pressure  is  in  great  part  applied  to  the 
vagina  and  uterus.  Halban  uses  one  to  three  pounds  of  shot  for 
counter-pressure  over  the  abdomen;  when  the  patient  lies  on  the  side 
the  bag  of  shot  is  retained  in  place  by  adhesive  straps.  This  pressure 
is  continued  for  not  less  than  an  hour,  and  may  be  prolonged 
throughout  the  entire  day. 

When  pain  is  caused  by  the  pressure  of  the  quicksilver  a  part  or  all 
of  it  must  be  removed  without  delay.  The  danger  of  continuing  the 
treatment  lies  not  alone  in  the  discomfort,  but  in  the  liability  of  exciting 
an  acute  exacerbation  of  a  subacute  or  chronic  inflammation,  and  in  the 
dissemination  of  an  unrecognized  virulent  infection.  ' 

In  the  diagnosis  of  pelvic  exudates  it  is  not  always  possible  to  exclude 
the  presence  of  a  virulent  infection,  hence  it  is  well  to  proceed  with 
caution  by  first  using  not  more  than  500  grams,  and  this  for  but  a 
short  time,  to  be  repeated  the  following  day  with  a  larger  amount  and 
for  a  longer  period.  If  pain  is  caused  the  treatment  is  discontinued, 
and  for  a  few  days,  rest,  hot  douches,  and  like  conservative  methods 
are  substituted,  to  be  then  followed  b}^  a  repeated  trial  of  the  pressure 
therapy.  If  pain  is  again  caused  the  treatment  should  be  abandoned 
for  other  conservative  methods. 


ELECTRICITY 

Little  need  be  said  of  electricity  as  a  therapeutic  agency  in  the 
treatment  of  diseases  of  women.  It  has  been  extolled  as  a  panacea 
for  almost  all  afflictions  of  women.  One  by  one  these  diseases  have 
been  removed  from  its  category  until  now  little  place  is  given  to  the 
consideration  of  the  subject  in  text-books  or  periodicals,  and  few 
gynecologists  find  any  place  for  electricity  in  the  treatment  of  diseases 
of  women.  Electricity  in  gynecology  has  had  its  day  and  now  finds 
no  place  in  rational  gynecological  therapy.  No  consideration  will 
therefore  be  given  to  the  subject  in  this  text. 


X-RAY  THERAPY 

There  is  a  limited  scope  for  the  application  of  the  .r-rays  in  the  treat- 
ment of  gynecological  diseases.  The  lesions  which  are  amenable  to 
this  form  of  treatment  are  either  rare,  are  seldom  recognized  early 
enough  to  insure  success,  or  else  are  inaccessible  to  the  influence  of  the 
rays.  There  are,  however,  selected  cases  in  which  the  .r-rays  are  of 
special  value. 

Indications. — Cancer. — Cancer  of  Uterus. — Cancer  of  the  uterus  in  its 
earliest  stages  never  calls  for  .r-ray  treatment,  but  demands  a  radical 


224  XOX-OPERATIVE  METHODS  OF   TREATMENT 

surgical  procedure.  Only  inoperable  cancers  of  the  cervix  and  recurrent 
cancerous  growths  after  hysterectomy  call  for  a  consideration  of  such 
tentative  measures.  The  treatment  is  in  no  sense  curative;  at  most 
it  can  only  clear  up  the  superficial  lesions  and  thereby  stay  the  dis- 
charges. Little  or  nothing  is  accomplished  in  relieving  pain  because 
of  the  impossibility  of  reaching  the  infiltrated  areas  in  the  deep-lying 
structures.  Insofar  as  the  .r-rays  check  the  wasting  discharges  they 
promote  nutrition,  and  if  they  serve  no  other  purpose  than  to  encourage 
the  patient,  they  are  not  without  value. 

In  one  instance  a  recurrence  of  a  cancer  of  the  cervix  occurred  one 
year  after  hysterectomy.  The  author  removed  a  growth  the  size  of  a 
hazel-nut  from  the  vault  of  the  vagina  and  in  five  days  it  had  returned 
to  double  the  original  size.  The  growth  was  again  excised  and  cauter- 
ization applied  as  deeply  as  seemed  safe.  During  the  following  year 
the  .T-rays  were  applied;  at  first  three  times  a  week  and  later  at  longer 
intervals.  There  has  been  no  sign  of  recurrence  in  the  ten  years 
following  the  last  operation. 

The  author  is  of  the  opinion  that  the  .r-rays  should  be  applied  to  the 
vault  of  the  vagina  after  convalescence  from  hysterectomies  done  for 
cancer  of  the  cervix.  AMien  properly  applied  they  can  do  no  harm 
and  may  do  good. 

Cancer  of  the  Vagina  and  Vulva. — Cancers  of  the  vagina  and  vulva 
are  more  accessible  to  the  application  of  the  .r-rays,  and  are  slower  in 
their  spread  than  cancers  of  the  uterus.  The  results  from  the  applica- 
tion of  the  .T-rays  are  therefore  better  than  in  cancer  of  the  cervix. 
The  treatment  is  usually  only  palliative,  but  in  some  instances  it  is 
curative.  It  is  not  to  be  understood  that  the  .r-rays  in  any  instance 
should  replace  surgery  when  the  lesion  is  operable,  but  should  be  applied 
as  a  supplementary  procedure  after  a  surgical  operation  and  the  healing 
of  the  wound.  In  inoperable  cancer  of  the  vulva  and  vagina  much  may 
be  done  with  the  rays  to  promote  comfort  and  to  prolong' life. 

When  a  cure  appears  to  have  been  effected  it  is  advisable  to  continue 
the  applications  of  the  rays  at  intervals  of  weeks  or  months  for  a  period 
of  several  years,  if  not  for  the  entire  life  of  the  individual. 

Sarcoma. — The  same  rules  should  apply  to  sarcoma  as  to  carcinoma, 
though  the  results  are  less  certain. 

Tuberculosis. — In  tuberculosis  of  accessible  regions  of  the  genitalia 
the  .r-rays  have  produced  most  gratifying  results.  The  response  to  the 
treatment  is  usually  prompt  and  a  complete  cure  may  be  expected  in 
a  few  weeks,  even  in  cases  which  have  advanced  to  ulceration.  Failure 
to  obtain  good  results  is  largely  accounted  for  by  faulty  technic  in 
the  application  of  the  rays,  and  in  not  recognizing  the  presence  of  the 
lesion  in  the  upper  genital  tract,  beyond  the  reach  of  the  rays. 

Pruritus  Vulvae. — A  number  of  successful  cases  have  been  recorded 
in  which  the  rays  have  been  applied  to  the  itching  area.  AMien  other 
means  have  failed  the  .r-rays  should  be  given  a  trial. 

Eczema. — In  the  chronic  indurative  stage,  eczema  usually  responds 
very  promptly  to  the  influence  of  the  r-rays.  Other  modes  of  treatment 


SWABS  225 

may  be  combined  with  their  application.  The  itching  will  usually 
cease  after  a  few  treatments. 

Lichen  Planus. — This  is  rarely  seen  on  the  vulva.  The  .r-rays  deserve 
a  trial  in  such  cases,  but  the  results  are  uncertain. 

Osteomalacia. — Osteomalacia  has  been  successfully  treated  by  the 
a;-rays.  The  results  are  obtained  by  producing  atrophy  of  the  ovaries. 
It  must  be  borne  in  mind  that  in  the  application  of  the  .r-rays  sterilization 
and  the  artificial  menopause  may  be  brought  about  through  atrophic 
changes  in  the  ovaries.  This  fact  has  led  to  the  application  of  the  rays 
in  cases  in  which  it  is  desired  temporarily  to  check  or  permanently 
to  do  away  with  the  menstrual  flow  by  directing  the  rays  to  the 
ovaries. 

Menorrhagia. — ^Menorrhagia  due  to  chronic  metritis,  subinvolution, 
uterine  fibroids,  and  muscular  insufficiency  of  the  uterus  has  been 
controlled  by  repeated  applications  of  the  rays.  The  effect  is  to  destroy 
the  functionating  capacity  of  the  ovary  and  in  time  to  cause  atrophy 
of  the  ovaries. 

Uterine  Fibroids. — Experiments  on  animals  have  demonstrated  that 
marked  changes  are  produced  in  the  ovaries  by  the  action  of  the  x-rays. 
There  is  degeneration  of  the  follicular  epithelium,  death  of  many 
of  the  ova,  sclerosis  of  the  bloodvessels,  and  finally  disappearance 
of  all  follicles.  The  follicles  are  replaced  by  hyaline  tissue.  Similar 
observations  have  been  made  on  the  human  ovary.  Small  hemorrhages 
have  also  been  noted  in  the  ovarian  cortex.  In  myomata,  nuclear 
degeneration  and  cellular  destruction  have  been  observed,  together 
with  minute  hemorrhages. 

Jaugeas  believes  that  the  a'-rays  should  be  applied  to  cases  in  which 
there  are  multiple  small  fibroids  scattered  in  the  uterine  wall.  They 
may  also  be  used  when  the  tumor  is  large  and  does  not  give  rise  to 
symptoms  demanding  immediate  relief.  Old  slow-growing  tumors  are 
not  much  influenced  by  the  .r-rays.  Jaugeas  applies  the  rays  alternately 
over  either  ovary  and  the  uterus.  Special  caution  must  be  exercised 
when  the  abdomen  is  heavy  with  fat  for  fear  of  producing  necrosis. 
Gauss  is  of  the  opinion  that  hemorrhages  can  be  controlled  in  every 
instance  by  repeated  applications  of  the  .r-rays;  these  should  be  made 
at  frequent  intervals  and  over  a  period  of  not  less  than  two  months. 

When  the  ovaries  lie  behind  large  tumors  no  results  will  be  obtained 
by  the  action  of  the  rays.  Whenever  degenerative  changes  are  suspected 
in  the  tumor  no  time  should  be  lost  in  applying  the  rays ;  such  cases 
are  preeminently  surgical. 


SWABS 

Indications 
Technic 

There  is  only  a  limited  field  of  usefulness  for  the  uterine  swab.    Too 
much  needless  and  even  harmful  use  has  been  made  of  the  swab  in 
office  practice. 
15 


226 


NON-OPERATIVE  METHODS  OF  TREATMENT 


Indications. — The  swab  has  a  legitimate  field  of  usefulness  in: 
Removal  of  Mucus  from  the  Cervical  Canal. — Before  making  topical 
applications  to  the  cervix  and  to  the  endometrium,  the  mucous  secre- 
tions which  cling  tenaciously  to  the  cervical  mucous  membrane  should 
be  removed  by  means  of  an  applicator  of  absorbent  cotton.  Sterility 
is  sometimes  due  to  a  plug  of  mucus  in  the  cervix,  and  pregnancy  has 
been  known  to  follow  upon  the  removal  of  such  a  plug.  Before  making 
applications  to  erosions  of  the  cervix  the  surface  should  be  cleansed  by 
swabbing  with  sterile  absorbent  cotton  on  a  dressing  forceps. 

Application  of  Escharotics  and  Antiseptics  to  the  Cervix  and  Endome- 
trium.— Much  harm  has  been  done  by  the  application  of  too  strong 
escharotics  and  antiseptics  to  these  surfaces.  It  may  be  further  charged 
that  too  often  these  applications  are  made  when  there  is  no  indication 
for  their  use.  There  are  but  two  indications  for  such  applications, 
i.  e.,  hemorrhage  in  which  styptics  are  occasionally  applied  and  chronic 
infection. 

Fig.   100 


Topical  application  to  the  cervix  by  means >of  a  swab. 


Technic. — The  patient  is  placed  in  the  lithotomy  or  Sims'  position 
and  the  cervix  exposed  by  a  bivalve  speculum  in  the  former  position 
and  by  a  Sims'  retractor  in  the  latter  position. 

When  it  is  necessary  to  dilate  the  cervix  this  may  be  done  under 
anesthesia  or  by  means  of  laminaria  or  tupelo  tents.  For  convenience 
the  author  is  in  the  habit  of  using  small  wooden  applicators  on  which  a 
film  of  absorbent  cotton  is  tightly  wrapped.  These  are  sterilized  and 
kept  in  a  sterile  receptacle.  A  dry  swab  is  first  inserted  to  remove  the 
mucus,  and  this  is  followed  by  one  or  two  medicated  swabs.    For  infec- 


SERUM  AND  ORGANOTHERAPY 


227 


tion  of  the  cervix  the  author  usually  employs  pure  formalin  or  a  5  per 
cent,  solution  of  zinc  chloride.  Without  an  anesthetic  it  is  needless 
to  attempt  to  swab  the  endometrium. 


Fig.   101 


Swabbing  the  cervix.    The  cervix  is  exposed  by  a  retractor  held  by  an  assistant.    The  cervix  is  grasped 
by  a  tenaculum  and  swabbed  with  a  sterile  probe  wrapped  with  sterile  absorbent  cotton. 


SERUM  AND  ORGANOTHERAPY 

Much  interest  has  been  manifested  during  recent  years  in  the  serum 
treatment  of  gynecological  diseases,  but  as  yet  no  definite  results  have 
been  obtained. 

Antitoxin  of  Diphtheria.— The  one  exception  to  the  above  statement 
is  in  respect  to  the  antitoxin  of  diphtheria.  In  diphtheritic  vulvo- 
vaginitis a  prompt  reaction  will  usually  follow  the  administration  of 
antitoxin.  The  rarity  of  true  diphtheritic  infection  of  the  genital  tract, 
and  particularly  in  the  non-puerperal  state,  provides  little  justification 
for  the  consideration  of  this  most  valuable  serum  in  this  text.  _ 

Ovarian  Extract.— Ovarian  extract  has  been  recommended  in  cases 
of  premature  menopause,  whether  from  unknown  causes  or  from  the 
removal  of  the  ovaries.  It  is  said  to  replace  the  lost  internal  secretion 
of  the   ovary,   which  has   a   controlling   influence  upon  the  general 


228  NON-OPERATIVE  METHODS  OF  TREATMENT 

metabolism,  and  nervous  equilibrium  of  the  individual.  The  author's 
experience  with  the  remedy  in  a  large  number  of  cases  has  never 
satisfied  him  that  it  is  of  any  special  value. 

Corpus  Luteum  Extract. — Corpus  luteum  extract  is  the  desiccated 
powder  of  the  ovaries  of  pigs  put  up  in  capsules  holding  5  grains  in 
each.  It  has  proved  of  great  value  in  the  author's  hands  in  controlling 
the  nervous  manifestations  incident  to  the  artificial  menopause.  He 
believes  it  should  always  be  given  shortly'  after  an  operation  in  which 
the  ovaries  have  been  removed  and  continued  for  a  period  of  at  least 
three  months.  The  dose  is  5  grains  three  times  daily.  Not  only  does 
the  corpus  luteum  extract  lessen  and  often  forestall  the  nervous  dis- 
turbances of  the  superinduced  menopause,  but  the  author  has  observed 
cases  in  which  sexual  desire  had  been  lost  for  one  or  more  years  after 
the  removal  of  the  ovaries  and  was  restored  by  the  administration  of 
corpus  luteum  extract.  IMore  than  this,  it  happens  in  a  small  percentage 
of  cases  in  which  the  ovaries  have  been  removed  that  the  menstrual 
cycle  will  proceed  as  long  as  corpus  luteum  extract  is  given.  It  is 
sometimes  possible  to  reestablish  the  menses  by  the  administration  of 
corpus  luteum  even  after  a  period  of  amenorrhea  of  twelve  to  eighteen 
months  following  the  removal  of  both  ovaries.  The  author  has  had 
good  results  in  about  three-fourths  of  the  cases  of  the  artificially  induced 
menopause,  but  he  has  had  little  success  with  the  corpus  luteum  extract 
in  the  management  of  the  natural  menopause. 

Thyroid  Extract. — Thyroid  extract  has  been  advocated  for  the  treat- 
ment of  fibroid  tumors  of  the  uterus  on  the  assumption  of  the  reciprocal 
trophic  relationship  existing  between  the  thyroid  gland  and  the  uterus, 
as  demonstrated  by  the  occasional  occurrence  of  uterine  atrophy  after 
thyroidectomy,  of  menstrual  disorders  in  goitre,  in  cretins,  and  in 
myxedema,  and  by  the  occasional  atrophy  of  the  thyroid  gland  follow- 
ing hysterectomy.  Few  clinical  observations  have  been  made  to  sup- 
port this  hypothesis,  and  consequently  no  conclusions  are  yet  possible. 

Pituitrin  as  a  Styptic  in  Gynecology. — ]\Iuch  has  been  written  recently 
concerning  the  use  of  the  extract  of  the  hypophysis  (pituitrin)  as  an 
oxytocic  and  hemostatic  in  obstetric  practice,  but  there  has  been  little 
said  of  its  application  in  gynecology.  Bab  extols  its  use  as  a  hemostat 
in  uterine  hemorrhages  due  to  metritis  and  inflammations  of  the  adnexse. 
He  obtained  good  results  in  94  per  cent,  of  his, cases.  In  some  of  these 
instances,  ergot,  hydrastis,  and  stypticin  had  failed.  A  subcutaneous 
injection  of  2  to  3  c.c.  was  given. 

Gonorrheal  Vaccine. — See  chapter  on  Gonorrhea  in  Women.     , 

Tuberculin. — See  chapter  on  Tuberculosis  in  Women. 

Vaccine  Treatment  of  Pelvic  Infections. — There  is  little  encouragement 
in  the  vaccine  treatment  of  either  acute  or  chronic  pelvic  infections. 
Polak  obtained  encouraging  results  in  the  treatment  of  225  cases,  both 
puerperal  and  non-puerperal.  His  best  results  were  obtained  when  the 
infection  was  localized  in  the  absence  of  a  bacteriemia.  He  employs 
the  mixed  vaccine  obtained  from  reliable  laboratories.  The  initial 
dose  given  was  25,000,000  to  100,000,000  organisms. 


CHAPTER  XII 
HYGIENE  AND  DRESS 


Htgienb  of  the  School-girl 
Physical  Training  in  Schools 
Public  Playgrounds  and  Baths 


Indoor  Exercise 
Dress 


Hygiene  of  the  School-girl. — It  is  encouraging  to  note  that  the 
public  school,  which  was  primarily  established  for  the  development 
of  the  mind  of  the  child,  is  enlarging  its  scope  and  is  today  giving 
serious  consideration  to  the  development  of  the  body.  As  a  result 
the  children  of  the  poor  find  conditions  in  the  school  more  favorable 
to  their  physical  development  than  in  their  homes.  Up  to  the  time 
of  puberty  there  should  be  no  distinction  made  between  the  work 
and  play  of  the  girl  and  the  boy.  It  is  at  this  time  of  life  that 
the  child  should  acquire  jSxed  hygienic  habits  and  in  this  the  home 
and  the  school  should  cooperate.  The  hours  of  play  and  of  rest,  the 
food  and  the  clothing,  are  matters  of  such  vital  importance  as  to  engage 
the  combined  efforts  of  parents  and  teachers.  The  child  who  comes 
to  school  without  sufficient  clothing  and  without  breakfast,  and  who 
has  neglected  the  morning  bath,  as  well  as  the  care  of  the  hair,  the 
teeth  and  nails,  is  more  in  need  of  instruction  and  assistance  in  the  care 
and  development  of  the  body  than  of  the  mind.  Means  for  giving  the 
needed  service  should  be  at  the  command  of  the  teacher. 

The  modern  school-girl  is  dressed  in  an  ideal  way.  The  dress  combines 
lightness  with  warmth,  there  is  an  absence  of  constriction  at  the  waist 
line,  the  clothing  is  evenly  distributed  and  hangs  from  the  shoulders, 
and  the  shoes  are  heavy  and  comfortable.  It  would  be  well  if  such  a 
dress  were  not  discarded  in  later  years. 

The  importance  of  medical  inspection  of  the  pupils  cannot  be  over- 
estimated. Many  children  are  physically  disqualified  for  receiving 
school  instruction,  and  it  is  at  this  time  that  many  defects  can  be 
remedied  which  if  left  uncorrected  and  unrecognized  would  lead  to 
permanent  disability.  Children  who  are  underfed,  who  have  adenoids, 
defective  vision,  and  scoliosis  are  placed  at  an  immense  disadvantage 
in  their  education.  It  is  estimated  that  90  per  cent,  of  children  who 
are  backward  in  their  lessons  are  physically  defective.  More  than  half 
the  children  who  enter  the  public  schools  are  in  need  of  medical  attention, 
and  it  may  be  affirmed  that  these  ailments,  if  allowed  to  exist,  will 
engender  in  girls  many  of  the  pelvic  disorders  which  become  manifest 
with  the  establishment  of  puberty.  The  underfed  child  cannot  assimi- 
late knowledge.  "  Good  nutrition,  therefore,  is  essential  to  good  educa- 
tion."    It  would  be  well  if  the  public  schools  in  this  country  would 


230  HYGIENE  AND  DRESS 

follow  the  example  of  some  of  the  European  schools  in  providing  break- 
fast and  luncheon  for  the  underfed  child. 

Thomas  Madden  Moore  is  quoted  as  saying:  "If  the  State,  for 
reasons  of  public  policy,  determines  that  all  children  shall  be  com- 
pulsorily  educated  from  their  earliest  years,  it  should  certainly  afford 
the  means  by  which  this  may  be  least  injuriously  and  most  effectively 
carried  out,  by  providing  sufficient  food  as  well  as  education  for  every 
pauper  child  compelled  to  attend  school." 

It  must  not  be  inferred  that  malnutrition  is  the  heritage  of  the  poor 
alone;  the  child  of  the  well-to-do  may  suffer  from  the  lack  of  plain, 
nourishing  food  and  an  oversupply  of  sweets  and  pastries. 

The  school  desk  is  an  important  factor  for  consideration.  A  faulty 
attitude  assumed  by  the  child  at  the  desk  leads  to  many  physical  defects 
which  may  have  an  important  bearing  in  later  life. 

Physical  Training  in  Schools. — The  effect  of  physical  training  in 
schools  is  apparent  to  all  who  have  had  opportunity  for  observation. 
This  effect  is  not  only  manifested  in  the  physical  development  of  the 
child,  but  in  the  mental  development  as  well.  Regular  systematic 
gymnastics  should  be  a  part  of  the  curriculum  of  every  public  and 
private  school,  and  should  be  demanded  of  the  children  of  the  rich  as 
well  as  of  the  poor.  Such  exercises  not  only  benefit  the  child  of  normal 
development,  but  will  correct  many  of  the  physical  defects  due  to  faulty 
posture  and  carriage.  The  gymnasium  is  of  special  value  to  the  girls 
because  of  the  greater  difficulty  experienced  in  having  them  take  the 
needed  outdoor  exercises.  There  should  be  no  distinction  made  between 
the  exercises  required  of  the  girls  and  that  of  the  boys  before  the  age 
of  puberty.  Up  to  this  time  there  is  no  essential  difference  in  their 
physique,  and  the  demands  for  their  development  are  identical.  The 
girls  should  be  encouraged  to  spend  several  hours  a  day  in  the  open 
air  in  their  sports. 

Pubhc  Play-grounds  and  Baths. — No  greater  boon  has  been  conferred 
on  the  children  in  large  cities  than  in  the  establishment  of  public  parks, 
play-grounds,  and  baths.  Children  of  the  crowded  tenement  districts 
who  live  in  poorly  lighted  rooms  are  afforded  the  opportunity  for  fresh 
air,  sunlight,  and  healthful  exercise.  More  than  this  there  is  a  watchful 
control  exercised  over  these  children  which  safeguards  them  from  injury 
and  develops  manly  and  womanly  qualities  in  them.  It  would  be 
well  if  public  laundries  were  also  established  in  crowded  tenement 
districts. 

All  these  conveniences  are  not  mere  luxuries,  they  are  absolute 
necessities,  if  the  right  sort  of  wage-earners,  wives,  and  mothers  is 
to  be  developed.  The  public  purse  can  well  aft'ord  to  make  adequate 
provision  for  them. 

Indoor  Exercise. — Whatever  adds  to  the  general  physical  develop- 
ment of  women  adds  to  the  sexual  development,  and  should  be 
encouraged.  Both  indoor  and  outdoor  exercises  are  more  appreciated 
today  than  at  any  time  in  the  history  of  the  American  race,  and  to 
this  fact  may  be  ascribed  much  that  has  contributed  to  the  well-being 


INDOOR  EXERCISE 


231 


of  women.  Golf,  tennis,  riding,  and  other  forms  of  exercise,  when 
judiciously  practised,  produce  a  healthy,  vigorous  type  of  women, 
and  in  this  general  improvement  the  sexual  organs  share. 

Indoor  exercises  are  of  value  as  adjuncts  to  the  treatment  of  diseases 
of  women.  The  capacity  of  the  lungs  and  the  development  of  the 
muscles  of  the  thorax  and  abdomen  have  much  to  do  with  the  equilib- 
rium of  the  circulation  in  the  pelvic  organs.  Hence  it  follows  that 
whatever  exercise  will  develop  the  capacity  of  the  lungs  and  the 
strength  of  the  abdominal  and  thoracic  muscles  wdll  tend  to  prevent 
displacement  of  the  uterus  and  congestion  of  the  pelvis. 


Fig.  102 


Fig.   103 


Fig.   104 


Deep  breathing.     The  shoulders 
and  chest  elevated. 


Contractions  of  the 
abdomen. 


Bending  backward  of 
body. 


Women  of  advanced  years  are  especially  in  need  of  such  exercise. 
Inasmuch  as  they  are  less  inclined  to  physical  activity  their  muscles 
become  relaxed  and  atrophied,  fat  accumulates  in  the  abdominal  wall 
and  omentum,  and  there  is  a  tendency  to  the  development  of  a  pen- 
dulous abdomen.     Such  a  condition  predisposes  to  uterine  displace- 


232 


HYGIENE  AND  DRESS 


Fig.   105 


ments  and  pelvic  congestion  with  all  their  attending  evils.  It  must 
not  be  assumed  that  the  accumulated  fat  is  the  offending  factor,  nor 
must  efforts  be  directed  solely  to  reduction  in  weight,  but  rather  to 
strengthening  the  retaining  power  of  the  abdominal 
wall  by  increasing  the  muscular  tone  through  well- 
directed  exercises. 

If  indoor  exercise  is  to  afford  the  best  results 
certain  conditions  must  be  maintained ;  the  clothing 
must  be  free  of  constriction — pajamas  are  preferred; 
the  room  must  be  supplied  with  an  abundance  of 
fresh  air,  yet  free  of  drafts;  the  bowels,  bladder, 
and  stomach  must  not  be  loaded,  and  finally  the 
exercise  should  be  taken  in  the  morning  before 
breakfast  and  in  the  evening  before  retiring. 
JMoreover,  it  is  essential  that  the  exercises  should 
be  taken  at  regular  intervals  and  not  be  subject 
to  the  whims  and  moods  of  the  individual.  They 
should  not  be  carried  to  the  point  of  fatigue,  and 
after  the  exercise  in  the  morning,  while  the  cir- 
culation is  yet  accelerated,  a  cold  bath  or  shower 
should  be  taken,  followed  by  vigorous  rubbing  of 


m 


Fig.   106 


Bending  forward  of  body. 
First  step. 


Bending  forward  of  body.     Second  step. 


the  body  with  a  coarse  towel.  After  the  evening  exercise  a  full  hot 
bath  should  be  taken  and  the  body  dried  with  a  soft  towel  and  the 
patient  should  then  retire  to  bed. 

There  are  certain  movements  which  are  especially  directed  toward 
the  object  desired.    Those  in  general  practice  are  the  following: 


IXDOOR  EXERCISE 


233 


Exercise  1. —  Deep  Breathing. — The  erect  posture  is  assumed  with  the 
hands  resting  upon  the  hips,  the  arms  akimbo.  The  chest  is  slowly 
expanded  to  the  full  capacity  of  the  lungs.  The  air  is  held  for  a  few 
seconds,  with  the  abdominal  muscles  tightly  contracted,  then  slowly 
and  completely  expelled.  This  exercise  should  be  repeated  six  times  in 
a  minute. 

Exercise  2. — Abdominal  Contractions. — The  erect  posture  is  assumed 
with  the  hands  resting  upon  the  hips,  the  arms  akimbo,  the  abdominal 
muscles  alternatelv  contracted  and  relaxed. 


Fig.   107 


Fig.  108 


^*^'® 

vS^ 


Bending  of  body  sidewise. 


T-sristing  of  bodJ^ 


Exercise  3. —  Trunk  Bending  Forward. — The  erect  posture  is  assumed, 
the  arms  are  stretched  vertically  above  the  head,  the  palms  facing 
forward,  and  the  thumbs  interlocked.  The  chest  is  slowly  expanded 
to  the  full  capacity  of  the  lungs,  the  abdominal  muscles  are  contracted 
tightly,  and  then  the  trunk  is  bent  upon  the  hips  without  bending  the 
knees^  m  the  effort  to  touch  the  tips  of  the  fingers  or  the  palms  of  the 
hands  to  the  floor.     A  deliberate  return  is  then  made  to  the  erect 


234 


HYGIENE  AXD  DRESS 


posture,  and  wliile  the  arms  are  being  slowly  lowered  to  the  side  the 
air  is  exhaled.  There  should  be  an  interval  of  ten  seconds  before 
the  exercise  is  repeated. 

Exercise  4. —  Trunk  Bending  Backward. — The  erect  posture  is  as- 
sumed, the  hands  resting  upon  the  hips  and  the  arms  akimbo. 
Under  full  expansion  of  the  chest  and  firm  contraction  of  the  abdomi- 
nal muscles,  the  body  is  slowly  bent  backward,  then  gradually 
straightened   again  and  the  air   exhaled. 


Fig.   1C9 


Raising  of  bodv.     First  step. 
Fig.   110 


Raising  of  bodj'.     Second  step. 


Exercise  5. —  Trunk  Bending  Sideicise. — The  erect  posture  is  assumed 
with  the  hands  resting  upon  the  hips,  the  arms  akimbo.  The  chest 
and  Imigs  are  fully  expanded  and  the  abdominal  muscles  contracted. 
The  trunk  is  then  slowly  bent  to  the  right  and  to  the  left  several  times 
in    succession. 

Exercise  6. —  Trunk  Twisting. — The  erect  posture  is  assumed,  the 
hands  resting  upon  the  hips,  the  feet  close  together,  the  legs  and  thighs 
rigid.  The  chest  and  lungs  are  fully  expanded,  the  abdominal  rnuscles 
tightly  contracted.  The  body  and  head  are  then  repeatedly-  rotated 
from  left  to  right  and  from  right  to  left. 

Exercise  7. —  Trunk  Raising. — The  body  lies  straightened  upon  the 
floor,  the  hands  resting  upon  the  hips,  the  feet  together,  a  full  breath 


INDOOR  EXERCISE 


235 


is  taken  and  then  the  body  is  slowly  raised  to  the  sitting  posture. 
The  orio-inal  posture  is  then  slowly  resumed  as  the  air  is  exhaled.  There 
should  be  a  rest  of  a  few  seconds  before  repeating  the  exercise. 


Fig.   Ill 


Raising  one  leg. 
Fig.  112 


Raising  both  legs. 

Exercise  8.-Le„  Rm.sing.-The  same  posture  is  assumed  as  in  Exer- 
cise r  Then  with  the  luigs  fully  expanded  and  the  knees  st.ftened, 


23() 


HYGIENE  AND  DRESS 


Fig.  113 


Dip  movement.     First  step. 
Fia.  114 


Dip  movement.     Second  position. 


Fig.   115 


Squatting  position. 


DRESS  237 

the  legs  are  slowly  elevated  to  a  right  angle  with  the  trunk;  as  they 
are  lowered  the  air  is  exhaled.  This  exercise  is  repeated  at  intervals 
of  a  few  seconds.  If  difficulty  is  experienced  in  elevating  both  legs 
together  they  may  be  elevated  alternately. 

Exercise  9. —  The  Dip  Movement. — Lying  prone  upon  the  face  and 
abdomen  with  the  palms  and  toes  upon  the  floor,  the  back,  neck,  and 
legs  stiffened,  a  full  breath  is  taken.  The  whole  form  is  elevated  upon 
the  arms  and  toes,  then  lowered  as  the  air  is  exhaled. 

Exercise  10. — Squatting. — With  deep  inspiration  in  the  erect  posture, 
the  hands  resting  on  the  hips,  the  patient  squats  so  that  the  buttocks 
are  close  to  the  heels.  She  then  straightens  up  and  exhales.  This 
movement  is  repeated  at  intervals  of  ten  seconds. 

Dress. — Faulty  habits  of  dress  are  responsible  for  many  of  the 
ailments  of  women.  The  chief  faults  are  combined  in  the  insufficient 
protection  from  dampness  and  cold  and  in  undue  constriction  and 
traction  about  the  waist.  As  a  result  of  insufficient  protection  the 
surface  of  the  body  becomes  chilled,  and  the  internal  organs,  particularly 
those  of  the  pelvis,  become  congested,  their  functions  deranged  and 
their  texture  altered.  The  pernicious  habit  of  wearing  thin-soled  shoes 
and  sleeveless,  low-necked  gowns  contributes  largely  to  the  disorders 
of  the  pelvic  organs. 

Three  essentials  to  dress  are  emphasized  by  Dudley,  whose  views 
are  in  accord  with  the  classical  paper  of  Dickinson.^ 

These  conditions  are: 

1.  Even  distribution  for  uniform  protection  against  cold  and  wet. 

2.  Freedom  from  waist  constriction. 

3.  Freedom  from  traction. 

1.  Even  Distribution. — In  this  respect  the  modern  dress  displays  an 
utter  disregard  of  hygienic  principles.  No  adequate  protection  is 
afforded  the  head;  the  neck,  shoulders,  and  arms  are  either  bare  or 
insufficiently  clad;  layer  upon  layer  of  cloth  bind  the  waist;  skirts  hang 
about  the  lower  extremities,  but  provide  little  warmth  and  do  immeas- 
urable harm  by  traction  and  constriction  of  the  waist;  the  legs  are 
poorly  protected  by  stockings;  and  tight  shoes  with  thin  soles  hamper 
the  free  action  of  the  feet  and  expose  them  to  cold  and  dampness. 
High  heels  tilt  the  body  forward,  thus  putting  undue  strain  upon  the 
muscles  of  the  back  and  contributing  to  backaches  and  fatigue  in  the 
effort  to  maintain  the  equilibrium  of  the  body.  More  than  this,  the 
normal  curves  of  the  spine  and  the  obliquity  of  the  pelvis  are  altered. 

2.  Waist  Constriction. — By  constricting  the  waist  with  corsets  and 
bands  the  muscles  of  the  abdomen  and  back  are  seriously  embarrassed, 
the  abdominal  viscera  are  displaced  and  their  functions  impeded;  the 
inability  to  perform  abdominal  respiration  impedes  the  action  of  the 
lungs  and  heart.  Passive  congestion  of  the  abdominal  and  pelvic 
organs  may  result  from  waist  constriction,  and,  as  a  consequence,  the 
menstrual  functions  become  deranged,  discomfort  is  complained  of  in  the 
pelvis  and  the  capacity  for  childbearing  is  limited  if  not  wholly  lost. 

1  Trans.  Amer.  Gyn.  Soc,  1893. 


238 


HYGIENE  AND  DRESS 


Fig.   116 


Furthermore,  the  stomach  is  compressed  and  its  functions  impaired. 
The  peristaltic  moA^ements  of  the  bowel  are  embarrassed,  leading  to 
constipation  and  intestinal  indigestion.  The  transverse  colon  and 
kidneys  are  crowded  downward.  In  short,  there  is  not  a  single  viscus 
in  the  chest,  abdomen,  or  pelvis  which  may  not  be  affected  directly 
or  indirectly  by  the  constriction  of  the  waist. 

While  it  is  apparent  that  the  corset  is  capable  of  much  harm,  it 
must  in  all  fairness  be  admitted  that  a  corset  may  be  so  made  and 
adjusted  that  it  will  do  no  harm  and  be  a  benefit  in  certain  particulars. 
This  statement  should  be  qualified,  however,  for  in  women  who  are 

compelled  to  assume  the  stooping  posture 
day  after  day  in  their  work,  any  sort  of  a 
corset  will  compress  the  abdomen. 

It  is  estimated  that  a  woman  who  draws 
in  her  sta^s  three  or  four  inches  places 
herself  under  a  direct  pressure  of  from 
twenty  to  thirty  pounds'  weight,  and  that 
this  pressure  is  increased  by  the  food  and 
liquids  taken  into  the  stomach,  by  the 
loading  of  the  bowel,  and  by  the  weight 
of  the  skirts  (Playfair). 

During  pregnancy,  constriction  of  the 
waist  is  particularly  apt  to  produce  dis- 
placements of  the  uterus,  and  may  be  the 
cause  of  abortions  and  malpositions  of  the 
fetus. 

At  this  juncture  it  may  be  well  to  refer 
to  the  abdominal  supporters  worn  in  the 
childbed    period.      Such    a   binder,  when 
tightly  applied,   operates  in  an  injurious 
way    by   increasing   the    intra-abdominal 
pressure,  and  thus  contributes  to  the  congestion  of  the  uterus.    Unques- 
tionably, not  a  small  percentage  of  displaced  uteri  are  accounted  for  in 
this  way. 

Fig.  117  Fig.  118 


Forward  bending.  Corset  steels 
forcing  the  pelvic  organs  downward. 
(Steele-Adams.) 


Undershirt 

ratvertf  ba7id 

Vhite  Drawers  band 
tinise 
.  Corset 

Corsei-cover 
Flannel-skirt  ba^id 
flTiite-skirt  band 
Dress-skirt  hand 
Dress-waist  lined 

17   LAYERS 

Layers  of  material  about  waist  in  old  style  of  dress. 
(Dickinson.) 


IJnion 
Undergarments 
Eqiiesfrirnne 

tighU 
Muslin  imi^t 

and  i^kirt 
Dress 


Layers  of  material  about  waist  in  new 
style  of  dress.     (Dickinson.) 


A  flabby  uterus,  slightly  supported  by  the  relaxed  ligaments  and 
pelvic  floor,  affords  little  resistance  to  the  intra-abdominal  pressure, 
but  the  author  would  not  be  understood  as  condemning  the  wearing 


DRESS 


239 


of  all  abdominal  supports  after  labor.  When  the  abdominal  walls 
are  greatly  relaxed,  a  properly  adjusted  binder  will  provide  the  needed 
support  to  the  viscera  and  add  to  the  comfort  of  the  mother. 

3.  Waist  Traction. — Corsets  and  waist-bands  prevent  the  free  exer- 
cise of  the  abdominal  and  dorsal  muscles.  This  leads  to  an  under- 
development of  these  muscles.  They  are  unable  to  withstand  the 
weight  of  the  skirts  without  fatigue.  In  this  fact  lies  one  explanation 
for  the  habitual  backache  of  women.  Moreover,  the  underdevelopment 
of  the  muscles  of  the  abdomen  weakens  the  expelling  powers  of  labor. 
Hence  it  follows  that  all  unnecessary  traction  at  the  waist  must  be 
eliminated. 


Body  forms  that  are  factors  in  questions  of  corset  postures  and  pressures.  A  thin  build  shows  a 
long  trunk  seriously  affected  by  constriction  during  adolescence.  A  square  build  and  broad  trunk 
may  be  squeezed  to  develop  fat  pad  deformities,  but  rarely  into  displacements  or  serious  defects. 
(Dickinson.) 


To  meet  the  conditions  necessary  to  provide  even  distribution  for 
uniform  protection  against  cold  and  wet,  together  with  freedom  from 
waist  constriction  and  traction,  Dudley  recommends  a  hygienic  dress 
composed  of  the  following  garments: 

1.  Union  undergarment. 

2.  Equestrienne  tights  (in  winter). 

3.  Muslin  or  silk  waist  and  skirt. 

4.  Dress  in  one  piece,  or  so  made  that  its  principal  weight  may  be 
distributed  over  the  shoulders,  bust,  and  hips.  These  garments  may 
be  modified  in  many  ways  to  suit  the  fancy  without  violating  the 
essential  principles — that  of  even  distribution  and  freedom  from  waist 
constriction  and  traction. 

Corsets. — In  a  series  of  observations  made  by  Dickinson  upon  the 
construction  and  physical  effects  of  the  corset,  he  finds  that  the  average 


Fig.   120 


'Kii'n  i^e.t  moved 


T\K"i^00d  cox^ct"  of 


shouUdfi 
forivdrd 


chin  foiwaii 
atid  foweud 


fiampered 

organs 
pusficd 
doivniv'd 

pcfcic 
contenb 
exposed 
to  pressure 
fromaMe 


l»    \    'yionV'^U^scotset, 
vicious  pc5turc  ^yie$$vic 


Fig.   122 


Fig.   123 


$f\c\itdix$  far  forward  of  ftipj 


fine 
uprigfit. 
ei  ' 
uearfy: 

prfjsuro 

(bseii 

upward 


3. 


'uarfiin^ 

faiify 

free 


oiijans 

nctpre^ill 

downward 

pcFvic  com 
teiib  feci? 
^om  fine 
ofprepure 


*^^dmn'maf  ccwct: 
^od  po5tuu,fowpie55Utt^ 


Figs.  121.  122,  123. — The  three  types  of  corset,  hourglass,  straight,  abdominal."  Vicious  pressures 
compared  with  tolerable  pressures;  harmful  forms  vs.  neutral;  bad  posture  or  good;  pelvic  inclination 
inviting  displacement  as  against  tilt  which  saves  from  pressures.  Picturesquely  unfavorable  instances 
of  the  first  and  second  class  are  here  selected  tocontrast  with  a  good  or  corrective  example  of  the  third. 
(Dickinson.) 


PLATE    XIII 


Govcr 


1   Clw 
|f  faper 


Ifacinj: 

m5mm 


ffasfic 


rroa^erv 


cfi 


'^eel  hr 


Simple  Method  of  Recording  Outlines. 

di'wjn?  LaJ?    'r  T:r.Ti:mT'''{       The   paper  is  dipped  to  wall    or 
knee  aetaon  is  shown  by  the  snug  sheet         Diekinso^.)  ^^      ^""^ 


DRESS  241 

corset  shows  little  effect  on  increase  in  the  vaginal  pressure  in  corseted 
women  whose  abdominal  walls  and  pelvic  floor  are  firm,  but  they  cause 
a  marked  rise  in  the  intrapelvic  pressure  from  exertion  in  women  whose 
muscles  are  flabby  and  whose  interior  supports  are  relaxed.  Dickinson 
is  of  the  opinion  that  the  tight  corset  does  little  harm  to  vigorous 
women,  and  great  harm  to  weak  women. 

The  woman  with  a  long  body,  compressed  chest,  and  sagging  viscera 
is  harmed  by  corsets.  Dickinson  attempts  to  group  the  various  types 
as  follows: 

1.  A  limited  number  of  women  who  are  not  seriously  affected  by 
excesses  in  pressure  and  constriction. 

2.  A  large  number  of  women  who  are  not  seriously  affected  by 
moderate  degrees  of  constriction. 

3.  A  large  number  of  women  in  whom  abdominal  constrictions 
gradually  induce  considerable  alterations  which  may  result  in  per- 
manent disability. 

4.  A  small  proportion  of  women  who  are  seriously  affected  by  slight 
departures  from  the  normal. 

To  estimate  the  amount  of  pressure  exerted  by  the  corset,  note  the 
gap  between  the  steels  on  loosening  the  corsets;  this  gap  should  not  be 
greater  than  two  inches.  The  hand  passed  within  the  corset  will  locate 
the  respective  points  of  pressure  and  will  roughly  indicate  the  degree 
of  pressure. 

Effect  of  Corsets  iqjon  Posture. — We  have  observed  the  effect  of 
faulty  posture  upon  backstrain  and  have  referred  to  this  factor  as 
a  frequent  cause  of  backache.  Corsets  may  correct  or  exaggerate  a 
faulty  posture,  hence  relieve  or  increase  backache. 

Dickinson  finds  that  the  normal  posture  calls  for  a  line  from  the  back 
of  the  buttocks  to  the  back  of  the  shoulders  that  inclines  forward  about 
one  inch,  i.  e.,  the  shoulders  are  about  one  inch  in  front  of  the  buttocks. 

Office  Test  of  Posture. — Dickinson  stands  the  patient  on  a  mark  on 
the  floor,  sidewise  to  a  paper  on  the  wall,  when  the  shoulder-blade 
and  buttocks  are  indicated  on  the  paper.  The  difference  in  these  two 
points  with  and  without  the  corset  will  demonstrate  the  effect  of  the 
corset  on  posture. 

Essentials  of  a  Well-fitting  Corset. — Following  are  the  essential 
features  of  a  well-fitting  corset: 

1.  Loose  at  the  top. 

2.  Waist  not  reduced  more  than  one  or  two  inches. 

3.  Laced  snug  at  the  hips. 

4.  Straight  front  with  little  or  no  incurve  at  the  waist. 

5.  Long  below  and  low  at  top. 

6.  Separate  lace  for  lower  six  or  eight  holes. 

7.  Support  large  breasts  independently  from  the  shoulders. 

8.  When  the  abdomen  is  large  or  the  abdominal  walls  relaxed  a 
front  lace  corset  should  be  adjusted  in  the  recumbent  position  or  the 
abdomen  may  be  raised  by  slipping  the  hand  inside  the  corset  before 
tightening  while  in  the  erect  position. 

16 


CHAPTER  XIII 
PREPARATION  OF  PATIENT  FOR  OPERATION 


Examinations    for    Contra-indica- 

TIONS 

Local  Treatments  Preparatory  to 
Operation 

Preparation  of  the  Field  of  Opera- 
tion 


Choice  of  Local  or  General  Anes- 
thesia 
Local  Anesthesia 
General  Anesthesia 
Spinal  Anesthesia 
Combined     Gynecological     Opera- 
tions 
Diet 


The  time  consumed  in  the  preparation  of  a  patient  for  a  major 
operation  depends  upon  two  factors:  (1)  The  urgency  of  the  indication 
for  the  operation;  (2)  the  condition  of  the  patient  in  reference  to  the 
general  nutrition,  blood,  kidneys,  and  respiratory  tract. 

Examination  for  Contra-indications. — When  there  is  no  contra-indica- 
tion  to  an  immediate  operation  from  the  causes  referred  to  below,  twenty- 
four  hours  will  be  sufficient  time  in  which  to  prepare  a  patient  for 
operation;  but  conditions  may  be  such  as  to  necessitate  a  delay  of 
days,  weeks,  and  possibly  months  before  an  operation  can  be  performed 
without  unwarranted  risk  to  life.  The  author  is  persuaded  that  lives 
are  not  infrequently  lost  by  failure  to  look  to  the  details  of  preparations 
for  operation.  The  following  are  the  main  considerations  in  the  pre- 
paratory management  of  operable  cases: 

Blood. — The  blood  should  be  examined  in  all  cases  before  proceeding 
with  an  operation,  and  no  major  operation  of  convenience  should  be 
undertaken  with  the  hemoglobin  lower  than  50  per  cent,  and  the 
number  of  red  cells  less  than  2,500,000.  If  the  patient  is  losing  blood 
more  or  less  continuously,  as  from  a  uterine  fibroid  or  carcinoma,  a 
preliminary  curettage  or  vaginal  pack  may  be  resorted  to  for  the 
purpose  of  checking  the  hemorrhage,  while  rest,  forced  feeding,  and 
tonics  are  administered.  By  such  a  process  the  author  has  seen  the 
blood  restored  at  the  rate  of  10  per  cent,  a  week. 

Heart. — When  the  heart  is  irregular  and  weak  in  its  action,  rest  in 
bed,  together  with  small  doses  of  strychnine,  should  be  enjoined  until 
the  heart  has  regained  its  strength  and  regularity  of  action.  Rest  in 
bed,  a  light,  nutritious  diet,  and  carefully  regulated  doses  of  strychnine 
and  digitalis  may  in  a  few  days  or  weeks  so  restore  the  action  of  an 
incompetent  heart  as  to  render  it  capable  of  withstanding  the  strain 
of  a  prolonged  operation. 

Irritation  of  the  Air  Passages. — When  there  is  acute  irritation  of  the 
air  passages  operation  should  be  delayed,  if  possible,  until  all  signs 
of  irritation  have  subsided.  Failure  to  observe  this  precaution  may 
precipitate  a  bronchopneumonia. 


LOCAL  TREATMENTS  PREPARATORY  TO  OPERATION       243 

General  Lowered  Vitality. — General  lowered  vitality  is  a  factor  which 
the  surgeon  would  do  well  to  consider  carefully  before  operating. 
Patients  with  low  resistance,  as  manifested  in  poor  nutrition,  a  low 
blood-count,  and  low  blood-pressure,  should  be  given  a  course  of 
rest,  feeding,  and  tonics  before  subjecting  them  to  an  operation  of 
convenience. 

Faulty  Secretions. — Faulty  secretions  may  constitute  a  justifiable 
contra-indication  to  operations  of  convenience.  If  the  urine  secreted 
is  below  the  normal  amount,  or  if  it  contains  morbid  elements,  such 
as  blood,  albumin,  and  casts,  operation  should  await  the  correction 
of  this  condition,  unless  it  be  an  emergency  that  will  brook  no 
delay. 

Local  Treatments  Preparatory  to  Operation. — The  haste  which 
characterizes  modern  life  is  exemplified  in  surgery.  This  criticism 
applies,  in  large  part,  to  the  management  of  pelvic  inflammations  in 
the  acute  and  subacute  stages.  Too  great  haste  in  surgical  intervention, 
under  such  conditions,  may  result  in  unnecessary  sacrifice  of  organs 
which,  by  tentative  mangement,  might  have  been  restored  to  functional 
if  not  organic  health.  More  than  this,  infections  which  are  localized 
may  be  extended,  and  with  disastrous  results,  if  attacked  early  in  their 
course. 

In  such  cases  non-interference  is  the  watchword;  rest,  hot  douches, 
and  glycerin — ichthyol  tampons  are  means  which  conserve  the  tissues 
and  prepare  them  for  possible  operations  in  which  the  hazards  will 
be  greatly  diminished.  This  is  not  true  of  the  chronic  forms  of  pelvic 
inflammation  wherever  located.  Here  local  preparatory  treatment  is  of 
no  value. 

As  will  appear  later,  many  cases  which  are  included  in  the  domain 
of  general  surgery  can  be  relieved  by  local  and  general  treatment,  but 
it  takes  a  clear  understanding  of  the  diagnosis  and  the  relative  values 
of  conservative  and  radical  measures  to  permit  of  a  ready  decision 
as  to  the  proper  procedure  to  be  adopted. 

In  the  days  of  Emmet,  at  a  time  when  surgical  cleanliness  could 
not  be  relied  upon,  operations  for  lacerated  cervix  and  perineum,  dis- 
placed uteri  and  abdominal  tumors  were  not  undertaken  without  local 
preparatory  treatment.  A  clearer  understanding  of  pathology  and  a 
greater  confidence  in  immediate  surgical  preparation  have  largely 
done  away  with  such  preparatory  measures.  This  does  not  apply  to 
fistulse  which  may  demand  careful  and  long  preparation  before 
operation. 

When  there  is  nothing  in  the  condition  of  the  patient  to  contra- 
indicate  an  immediate  operation,  the  time  for  the  preliminary  prepa- 
rations need  not  exceed  twenty-four  hours. 

Only  when  confronted  with  an  emergency  should  the  preliminary 
preparation  of  the  field  of  operation  be  omitted.  A  double  prepara- 
tion of  the  field  of  operation  should  be  the  rule  several  hours  before 
the  operation;  the  second  immediately  preceding  the  operation,  either 
before  or  after  anesthesia.     The  author's  preference  is  to  make  the 


244  PREPARATION  OF  PATIENT  FOR  OPERATION 

second  preparation  of  the  field  of  operation  after  the  anesthesia  is 
well  started,  unless  there  is  special  reason  for  shortening  the  time  of 
anesthesia,  the  patient  nervous,  or  the  scrubbing  causes  too  great 
discomfort.  It  is  expected  that  the  patient  will  reach  the  stage  of 
relaxation  in  the  anesthesia  by  the  time  the  preparatory  measures 
are  completed. 

Diet. — Twenty-four  hours  or  more  before  operation  the  diet  should 
be  light  and  nutritious  and  the  bowels  thoroughly  evacuated. 

Cartharsis. — The  author  has  never  deemed  it  necessary  to  deviate 
from  the  established  rule  practised  years  ago,  that  of  giving  1  or  2 
grains  of  calomel  and  sodium  bicarbonate,  followed  in  six  to  eight 
hours  with  |  ounce  of  Epsom  salt;  again  in  six  hours  with  a  high 
colonic  flushing,  given  in  the  knee-chest  position,  and  finally  a  low 
colonic  flushing  given  three  hours  before  the  operation.  Other  cathar- 
tics may  be  given,  with  perhaps  equally  good  results.  By  thoroughly 
cleansing  the  bowel  there  will  be  less  distress  from  gas  pains  subsequent 
to  the  operation,  and  in  vaginal  operations  there  is  not  the  likelihood 
of  soiling  the  field  of  operation. 

Stimulation. — As  a  rule  no  stimulation  should  be  given  before  the 
operation.  It  is  found  that  the  patient  suft'ering  from  depression  during 
the  operation,  reacts  more  promptly  to  stimulation  when  she  has  not 
been  stimulated  prior  to  the  operation.  A  good  precautionary  measure 
against  postoperative  vomiting  is  to  encourage  the  drinking  of  large 
quantities  of  water  up  to  two  hours  before  the  anesthetic. 

Combined  Abdominal  and  Vaginal  Preparation. — Whether  a  vaginal 
or  abdominal  operation  is  proposed,  it  is  wise  to  take  the  precaution 
to  prepare  both  the  vagina  and  abdomen,  because  of  the  uncertainty 
which  attends  such  a  large  proportion  of  gynecological  operations.  Before 
beginning  an  operation  it  is  not  possible  to  say  with  absolute  certainty 
that  it  will  not  be  necessary  to  open  into  the  vagina  for  the  purpose 
of  drainage  or  the  removal  of  the  uterus.  In  like  manner  a  proposed 
vaginal  operation  may  lead  to  the  opening  of  the  abdomen  through 
the  finding  of  an  unsuspected  condition  in  the  pelvis  or  the  accidental 
perforation  of  the  uterus. 

Preliminary  Examination. — When  the  patient  is  relaxed  under  anes- 
thesia, and  before  the  operation  is  begun,  it  should  be  the  invariable 
rule  to  make  a  bimanual  examination,  for  unsuspected  conditions  may 
in  this  way  be  revealed.  Such  preliminary  examinations  prior  to 
operation  may  alter  the  decision  of  the  operator  and  cause  him  to 
do  a  vaginal  rather  than  an  abdominal  operation,  and  vice  versa;  hence 
the  advisability  of  preparing  both  the  vagina  and  abdomen  in  all 
proposed  operations  on  pelvic  lesions.  Failure  to  do  so  will  occasionally 
lead  to  great  embarrassment  to  the  operator  and  add  unwarranted 
risks  to  the  patient. 

Preparation  of  the  Field  of  Operation. — A  great  variety  of  methods 
is  employed  in  the  preparation  of  the  field  for  operation.  All  have 
merit  and  no  one  excels  over  all  others.  The  following  is  the  method 
which  the  author  employed  for  many  years : 


PREPARATION  OF  THE  FIELD  OF  OPERATION 


245 


Preparation  of  Abdomen. 

A,  Preliminary  (twelve  to  twenty-four  hours  before  operation). 

1.  Scrub  with  green  soap  and  sterile  water. 

2.  Shave  the  entire  abdomen,  groin,  vulva,  and  chest  to  the  level 
of  the  breasts. 

3.  Scrub  ten  minutes  with  green  soap,  sterile  water,  and  sterile  gauze. 

4.  Wash  with  sterile  water. 

5.  Wash  with  alcohol,  95  per  cent. 

6.  Wash  with  ether. 

7.  Apply  creolin  solution,  1  per  cent. 

8.  Apply  dressing  of  dry  sterile  gauze  and  binder. 

Fig.  124 


Painting  the  abdomen  -nith  iodine  and  alcohol,  equal  parts. 


B.  Immediate  preparation  before  or  after  anesthesia. 

1.  Scrub  with  alcohol. 

2.  Apply  solution  of  creolin  eight  parts  and  glycerin  two  parts, 
rubbing  well  into  the  skin  for  three  minutes. 

3.  Remove  creolin  solution  with  sterile  gauze  and  wash  with  alcohol. 

4.  Cover  patient  with  sterile  sheets  and  towels. 

Iodine  Sterilization. — In  the  past  two  years  the  author  has  used  the 
iodine  preparation  on  the  abdomen,  with  good  result,  and  has  practically 
discarded  the  above  method  because  the  iodine  sterilization  is  equally 
trustworthy  and  is  far  more  convenient.     The  method  consists  in: 

1.  Dry  shave. 

2.  Scrub  with  alcohol  or  benzine. 

3.  Paint  field  of  operation  with  3  per  cent,  tincture  of  iodine. 

4.  Wait  ten  minutes. 


246  PREPARATION  OF  PATIENT  FOR  OPERATION 

5.  Paint  again  with  3  per  cent,  tincture  of  iodine.  When  the  patient 
can  be  prepared  on  the  previous  day  the  author  carries  out  the  usual 
preparation  of  scrubbing,  shaving,  washing  with  alcohol,  and  applying 
a  sterile  pad  and  binder.  He  is  not  convinced,  however,  that  such 
precautions  add  security  to  the  patient. 

Preparation  of  Vulva  and  Vagina. 

A.  Preliminary. 

1.  Scrub  with  green  soap  and  sterile  water. 

2.  Shave  external  genitals  and  inner  aspect  of  thighs. 

3.  Wash  with  sterile  water. 

4.  Cleanse  vagina  with  green  soap  and  sterile  water,  using  only  the 
fingers  rather  than  gauze  in  scrubbing,  for  fear  of  removing  the  vaginal 
epithelium. 

5.  Irrigate  vagina  with  sterile  water. 

6.  Apply  1  per  cent,  solution  of  creolin  to  vagina,  scrubbing  well 
with  the  fingers. 

7.  Scrub  external  genitals  with  creolin  solution,  1  per  cent. 

8.  Apply  perineal  dressings  preparatory  to  operation. 

Iodine  Sterilization. — It  will  be  found  perfectly  safe  to  swab  the 
vagina  and  external  genitals  with  3  per  cent,  tincture  of  iodine. 

Choice  of  Local  or  General  Anesthesia. — When  all  things  are  made 
ready  for  an  operation  the  choice  of  the  anesthetic  devolves  upon  the 
operator.  The  greater  the  experience  of  the  operator  the  more  does 
the  importance  of  this  task  appeal  to  him,  for  with  experience  comes  an 
appreciation  of  the  dangers  involved  in  individual  cases.  The  surgeon 
of  experience  knows  that  no  anesthetic  is  without  some  element  of 
danger,  that  every  case  is  a  law  unto  itself  and  demands  special  con- 
sideration in  the  choice  of  anesthetic.  There  are  cases  in  which  the 
operation  is  so  slight  that  neither  general  nor  local  anesthesia  is  required. 
The  slight  discomfort  in  the  procedure  would  not  justify  the  risk, 
however  slight,  of  a  general  or  local  anesthetic.  There  are  other  cases 
in  which  there  is  profound  depression  from  sepsis  or  hemorrhage,  or 
the  heart,  lungs,  or  kidneys  are  in  such  a  condition  as  to  contraindicate 
the  use  of  any  general  anesthetic.  Such  cases  compel  the  operator  to 
resort  to  local  anesthesia  or  to  abandon  all  anesthetics. 

All  sorts  of  operations  have  been  performed  with  endermic  injections 
of  cocaine  or  Schleich's  solution  without  the  degree  of  suffering  that 
would  be  expected.  Vaginal  and  abdominal  operations  are  performed 
under  local  anesthesia,  with  surprisingly  little  pain,  provided  no  trac- 
tion is  made  upon  peritoneal  ligaments  and  mesentery.  The  author  has 
performed  as  capital  operations,  with  the  aid  of  local  anesthesia  alone 
as  with  general  anesthesia,  and  the  results  have  been  equally  satis- 
factory. In  all  these  cases  the  condition  of  the  patient  presented  positive 
contra-indications  to  the  administration  of  a  general  anesthetic  and 
yet  would  brook  no  delay. 

Such,  for  example,  were  cases  of  ruptured  tubal  pregnancy,  with  the 
escape  of  a  large  quantity  of  blood,  and,  again,  of  profound  sepsis 
associated  with  great  depression. 


CHOICE  OF  LOCAL  OR  GENERAL  ANESTHESIA 


247 


It  is  the  rule  of  the  author,  when  operating  under  local  anesthesia 
in  major  cases,  to  have  an  assistant  drop  upon  an  Esmarch  inhaler  a 
mixture  of  alcohol  and  wintergreen.  This  the  patient  believes  to  be 
an  anesthetic.  By  this  ruse,  and  with  words  of  assurance  from  the 
operator  and  anesthetizer,  she  is  carried  through  the  operation  with 
much  less  suffering  than  would  be  expected.  While  a  general  anesthetic 
facilitates  the  operation,  and  without  it  the  niceties  of  technic  cannot 
always  be  accomplished,  it  must  be  borne  in  mind  that  the  purpose  of 
the  operation  is  to  restore  health  and  save  life,  and  to  this  end  the 
first  consideration  is  that  of  the  safety  of  the  patient.  Unquestionably 
general  anesthesia  is  frequently  resorted  to  when  a  local  anesthetic  or 
no  anesthetic  whatsoever  should  be  given. 

Fig.   125 


Operating  room  in  hospital. 


Patient  in  Trendelenburg  position  preparatory  to  making  an 
abdominal  incision. 


Local  Anesthesia. — ^When  the  field  of  operation  is  superficial  and 
limited  to  a  small  area  a  local  anesthetic  will  usually  suffice.  When  a 
general  anesthetic  is  contraindicated  in  major  vaginal  or  abdominal 
operations  the  initial  incision  through  the  vaginal  or  abdominal  wall 
may  be  made  painless  by  a  local  anesthetic.  The  further  steps  of  the 
operation  can  usually  be  taken  without  creating  great  suffering  on  the 
part  of  the  patient. 

Cold. — The  application  of  cold  to  the  surface  in  the  form  of  a  spray 
of  ethyl  chloride  benumbs  the  surface  by  paralyzing  the  sensory  nerves. 
The  spray  is  applied  for  about  five  minutes  or  until  a  crust  of  ice  forms 


248  PREPARATION  OF  PATIENT  FOR  OPERATION 

upon  the  surface  at  the  point  of  incision.  Bengue's  ethyl  chloride  is 
supplied  in  vials  containing  30  grains.  These  vials  are  provided  with 
brass  tips  containing  a  capillary  opening  and  screw-top.  Anesthesia 
may  be  almost  as  effectively  accomplished  by  applying  a  bag  filled 
with  cracked  ice  and  salt  for  five  or  ten  minutes. 

Cocaine. — The  hydrochlorate  of  cocaine  may  be  applied  to  the 
surface  of  the  mucous  membranes  or  injected  under  the  skin.  An 
application  to  the  surface  of  the  vaginal  mucosa  will  not  anesthetize 
the  tissues;  here  an  injection  is  required  as  in  skin  surfaces.  Injections 
of  cocaine  into  the  urethra  and  rectum  are  dangerous.  Under  a  2  per 
cent,  cocaine  anesthesia,  vulvar  and  vaginal  cysts  may  be  removed,  the 
urethra  may  be  dilated  with  little  pain,  and  polyps  may  be  removed. 
In  exceptional  cases,  perineorrhaphy  and  colporrhaphy  may  be  per- 
formed; but,  as  a  rule,  little  can  be  accomplished  in  the  relief  from 
pain  because  the  anesthetic  effect  of  the  cocaine  does  not  persist 
throughout  the  operation. 

Schleich's  Solution. — This  solution  consists  of  morphine,  cocaine,  and 
normal  salt  solution.  It  has  been  found  less  dangerous  and  more 
efficient  than  cocaine  as  a  local  anesthetic.  By  the  hypodermic  injection 
of  Schleich's  solution  the  nerve  terminals  are  paralyzed  through  pressure. 
The  needle  is  thrust  under  the  skin  in  a  nearly  perpendicular  direction, 
and  the  fluid  is  forcibly  injected  until  the  skin  is  elevated  and  blanched. 
Successive  injections  are  made  at  the  periphery  of  the  swelling,  along 
the  line  of  incision.  No  time  should  be  lost  in  the  making  of  the  incision 
after  the  injections.  It  is  probable  that  the  injection  of  normal  salt 
solution  will  be  found  equally  as  efficacious. 

General  Anesthesia. — The  choice  of  anesthetic  will  depend  upon  the 
condition  of  the  patient,  with  particular .  reference  to  the  respira- 
tory tract,  heart,  kidneys,  blood,  and  the  general  resistance  of  the 
individual.  In  the  United  States  ether  is  generally  regarded  as  the 
safest  of  the  general  anesthetics  when  not  contraindicated  by  irritation 
of  the  respiratory  tract. 

Anesthetizer. — There  can  be  no  more  fatal  error  than  to  fail,  to 
appreciate  the  responsibilities  of  the  anesthetizer.  To  relegate  the 
administration  of  the  anesthetic  to  an  inexperienced  assistant  is 
an  unpardonable  act.  The  choice  of  the  anesthetizer  is  only  second- 
ary to  that  of  the  operator,  and  equal  experience  and  skill  should  be 
demanded  of  both.  Equally  to  be  condemned  is  an  anesthetizer 
who  permits  himself  to  be  absorbed  in  the  operative  procedure  and 
fails  to  be  attentive  to  his  duties.  An  inexperienced  or  careless 
anesthetizer  either  harasses  the  operator  by  failing  to  keep  the  patient 
relaxed  or  endangers  the  life  of  the  patient  by  giving  an  unwarranted 
amount  of  anesthetic.  When  a  competent  anesthetizer  is  employed  the 
decision  as  to  the  time  and  amount  of  stimulation  should  rest  with 
him.  The  anesthetizer  should  always  be  provided  with  a  mouth  gag, 
tongue  retractor,  bits  of  gauze  held  by  forceps  with  which  to  swab 
the  mucus  from  the  throat,  and  a  watch  to  note  the  pulse  rate.  Failure 
to  observe  these  precautions  have  not  infrequently  led  to  fatal  error. 


CHOICE  OF  LOCAL  OR  GENERAL  ANESTHESIA  249 

Signs  of  Complete  Anesthesia: 

1.  Complete  muscular  relaxation. 

2.  Deep,  slow  and  regular  breathing. 

3.  Contracted   pupils. 

4.  Loss  of  pupil  reflex. 

Signs  of  Danger. — When  the  anesthetic  has  been  pushed  too  far 
the  first  approach  of  danger  is  usually  observed  in  the  grayish  pallor 
of  the  face.  The  pulse  becomes  feeble  and  rapid,  possibly  irregular, 
and  the  respirations  shallow  and  slow  until  both  become  imperceptible. 
The  blood  from  the  wound  becomes  dark  and  may  cease  to  flow.  The 
pupils  are  dilated  and  fixed. 

Resuscitation  of  the  Patient. — Prompt  and  masterly  action  is 
demanded  of  the  anesthetist  when  signs  of  danger  arise.  A  feeble 
pulse,  cessation  of  the  respirations,  dilated  pupil,  and  pallor  point  to 
impending  death,  and  no  time  should  be  lost  in  putting  into  force  all 
known  methods  of  restoration.  The  foot  of  the  table  should  be  raised 
to  an  angle  of  40  to  50  degrees;  the  operation  must  be  suspended;  all 
open  vessels  secured  with  hemostatic  forceps;  the  wound  covered 
with  warm  sponges;  the  jaws  held  forward  and  upward  and  the  tongue 
retracted  by  means  of  especially  constructed  forceps  which  should 
always  be  at  hand.  If  necessary  to  resort  to  artificial  respiration  the 
Sylvester  method  should  be  employed.  The  head  is  made  to  fall 
slightly  backward  by  elevating  the  thorax  with  a  small  pillow.  The 
surgeon  standing  at  the  head  of  the  patient  grasps  both  wrists  and 
elevates  both  arms  above  the  patient's  head,  drawing  them  upward 
and  outward  so  as  to  describe  a  circle.  By  so  doing  the  pectoral 
muscles  expand  the  chest.  The  arms  are  then  lowered  and  are  made 
to  compress  the  chest  firmly,  thereby  forcing  the  air  out  of  the  lungs. 
These  movements  are  repeated  at  intervals  of  three  to  five  seconds 
until  respiratory  movements  are  reestablished. 

Gas  Anesthesia. — In  the  author's  experience  he  has  found  the 
greatest  satisfaction  in  the  employment  of  gas  for  operations  of  short 
duration  and  as  a  preliminary  to  ether  anesthesia.  He  has  never 
attempted  the  prolonged  administration  of  gas,  but  as  a  preliminary 
measure  to  ether  anesthesia,  time  and  ether  are  saved  and  the  patient 
is  spared  the  distressing  experiences  of  struggling  under  ether  during 
the  preliminary  stages  of  excitement. 

Ether  Anesthesia. — Care  should  be  exercised  in  the  selection  of 
a  pure  brand  of  sulphuric  ether.  The  only  absolute  contraindication 
to  the  use  of  ether  is  laryngeal  and  bronchial  catarrh.  Nephritis  has 
been  generally  regarded  as  a  contraindication,  but  there  is  probably 
no  rational  basis  for  this  belief.  Many  of  the  inhalers  on  the  market 
are  cumbersome,  and  only  serve  to  burden  and  confuse  the  anesthetizer. 
As  an  improvised  inhaler  a  cone  made  of  stiff  paper  and  towel  still 
remains  in  general  favor.  In  the  author's  judgment  the  safest  pro- 
cedure is  the  drop  method,  in  which  the  ether  is  dropped  from  a  can  or 
bottle  upon  an  Esmarch  inhaler  in  the  same  manner  as  chloroform  is 
administered,  but  in  larger  quantities. 


250  PREPARATION  OF  PATIENT  FOR  OPERATION 

It  is  an  error  to  force  the  ether  upon  the  patient;  it  should  be  given 
slowly  and  continuously.  When  the  patient  gags  and  vomits  the 
mask  should  not  be  removed,  but  the  ether  should  be  continued 
until  the  spasmodic  efforts  of  the  patient  are  under  control.  Ripened 
judgment  is  required  after  general  relaxation  is  obtained  and  constant 
vigilance  is  exacted  of  the  anesthetizer  in  order  that  neither  too  little 
nor  too  much  ether  be  given. 

Chloroform. — While  chloroform  is  the  anesthetic  of  choice  in 
Europe,  and  indeed  in  the  Southern  States,  there  is  a  general  prejudice 
against  its  use  in  the  Northern  States.  While  the  patient  is  put  to  sleep 
in  less  time,  with  less  discomfort  and  the  disagreeable  after-effects  are 
minimized  as  compared  with  ether,  the  hazards  to  life  are  proportion- 
ately great.  Adulteration  of  the  product  increases  the  risks,  and  hence 
the  greatest  care  should  be  exercised  in  the  selection  of  the  brand.  The 
one  absolute  contraindication  to  the  use  of  chloroform  is  an  incompetent 
heart.  Valvular  lesions  of  the  heart  in  the  presence  of  good  compensa- 
tion offer  no  contraindication.  According  to  Hare,  chloroform  is  more 
irritating  to  the  kidneys  than  ether.  Whenever  it  is  essential  that 
struggling  shall  be  avoided,  chloroform  is  preferred.  In  such  cases  it 
is  well  to  precede  the  administration  of  chloroform  by  the  hypodermic 
injection  of  J  grain  of  morphine,  given  a  half-hour  in  advance. 

Hare  affirms  that  death  from  chloroform  is  more  often  the  result  of 
respiratory  than  of  cardiac  paralysis.  As  a  rule  the  pulse  fails  earlier 
than  the  respiration.  The  administration  of  chloroform  should  never  be 
wholly  intrusted  to  an  inexperienced  assistant.  Unlike  ether  anesthesia 
the  mask  should  be  removed  when  the  patient  vomits  or  the  throat 
fills  with  mucus,  and  should  not  be  replaced  until  the  struggling  ceases. 

Spinal  Anesthesia. — For  a  time  much  was  expected  of  the  injection 
of  cocaine  into  the  subdural  space  of  the  cord  for  anesthesia  of  the 
abdomen  and  lower  extremities,  but  it  may  be  safely  affirmed  that  there 
is  no  place  for  the  procedure  in  view  of  its  many  dangers. 

Combined  Gynecological  Operations. — The  term  combined  gyneco- 
logical operations  implies  the  performance  of  two  or  more  gynecological 
operations  under  the  same  anesthesia. 

Advantages  of  Combined  Operations. — Two  or  more  lesions  com- 
monly exist  in  the  pelvis  and  together  contribute  to  the  symptom- 
complex.  It  is  self-evident  that  failure  to  correct  all  of  the  lesions  will 
result  in  failure  in  obtaining  complete  relief.  For  example,  a  displaced 
uterus  should  not  be  restored  to  its  normal  position  without  correcting 
any  existing  defect  in  the  pelvic  floor  and  vaginal  walls.  Furthermore, 
lesions  resident  in  the  appendages  and  appendix  should  receive  due 
consideration.  Again,  when  the  uterus  and  its  appendages  are  in- 
fected it  will  serve  no  good  purpose  merely  to  curet  the  uterus;  the 
lesions  resident  in  the  upper  genital  tract  should,  at  the  same' time, 
be  disposed  of. 

Pain,  hemorrhage,  leucorrhea,  and  sterility  are  the  complaints 
common  to  gynecological  cases.  One  or  all  of  these  complaints  may  be 
due  to  a  single  lesion,  but  not  uncommonly  there  is  a  combination  of 
lesions,  each  contributing  its  share  to  the  symptom-complex,  hence 


DIET  251 

the  importance  of  looking  beyond  a  single  lesion  for  the  cause  of  a 
symptom  or  group  of  symptoms.  ^Yhen  two  or  more  contributing 
factors  are  found  to  account  for  the  complaints,  all  should  be  removed 
under  a  single  anesthetic  if  the  physical  resistance  of  the  patient  and 
the  time  limit  of  the  operation  will  permit. 

In  the  course  of  an  operation  minor  lesions  are  often  disposed  of 
which  in  themselves  might  not  justify  operative  intervention,  i.  e., 
cystic  ovaries,  small  superitoneal  fibroids,  and  relaxed  uterine  supports 
without  displacement  of  the  uterus. 

When  the  low  vitality  of  the  patient  will  not  permit  an  extended 
operation  or  the  combined  work  required  is  too  great  for  a  single  anes- 
thetic it  is  advisable  to  perform  the  operation  in  two  or  more  steps, 
but,  as  a  rule,  all  work  should  be  completed  before  the  patient  leaves 
the  hospital. 

Diet. — It  is  important  for  the  surgeon  to  be  well  informed  in  dietetics, 
but  the  scope  of  this  work  does  not  permit  an  extended  discussion  of 
the  subject.  In  selecting  a  suitable  diet  for  a  patient  the  first  con- 
sideration is  that  of  nourishment  and  the  second  is  that  of  palatability. 
To  meet  the  varied  requirements  of  individuals  it  is  essential  to  have 
a  thorough  knowledge  of  dietetics. 

Liquid  Diet. — It  is  the  author's  custom  to  prescribe  nothing  but 
liquid  diet  for  the  first  twenty-four  hours  following  a  major  operation. 
As  a  rule,  milk  should  be  excluded  from  the  diet  list  until  the  functions 
of  the  digestive  tract  are  well  established,  and  this  generally  requires 
several  days  following  the  operation.  In  the  first  twenty-four  to  forty- 
eight  hours  the  diet  should  consist  of  broths,  gruels,  bouillon,  albumen 
water,  and  beef  juice.  These  may  be  given  at  four-  to  eight-hour 
intervals,  and  in  small  quantities.  If  milk  is  given  at  this  early  date  it 
is  well  to  add  lime  water,  Vichy,  or  Seltzer.  To  add  to  the  digestibility 
of  milk  the  contents  of  one  of  Fairchild's  peptonizing  tubes  may  be 
dissolved  in  four  ounces  of  water  and  one  pint  of  milk.  This  may  be 
given  either  hot  or  cold.  ]Milk  may  be  albumenized  by  adding  the  white 
of  an  egg  to  two  ounces  of  milk,  this  to  be  stirred  gently  with  a  spoon, 
care  being  taken  to  avoid  coagulation  of  the  albumen.  Again,  the 
milk  may  be  rendered  more  digestible  by  pasteurizing  at  a  temperature 
of  160°  F.  for  one-half  hour.  Koumiss  is  digestible  and  palatable  to 
many  patients.  A  good  substitute  for  koumiss  is  buttermilk,  served 
either  hot  or  cold.  Egg-nog  may  be  served  between  meals  when  forced 
feeding  is  desired.  Whisky,  sherry,  or  brandy  may  be  added  in  small 
quantities. 

Soft  Diet. — In  all  but  exceptional  cases  a  soft  diet  may  be  given 
the  second  or  third  day  following  operation.  In  addition  to  the  food- 
stuffs mentioned  under  liquid  diet,  there  are  added  such  articles  as  soft- 
boiled,  poached,  or  scrambled  eggs,  baked  or  creamed  potatoes,  toast 
(dry,  milk,  or  cream),  cereals  (oatmeal,  cream  of  wheat,  cracked  wheat), 
fruit  (stewed  prunes,  baked  apple,  oranges),  egg  custards,  corn-starch 
pudding,  and  rice  pudding. 

It  is  well  to  withhold  all  meats,  vegetables,  and  fruits  not  included  in 
this  list  until  the  patient  is  well  on  the  way  to  recovery. 


CHAPTER  XIV 
PRINCIPLES  OF  ASEPSIS  IN  GYNECOLOGY 

Sterilization   of  Field   of   Opera-  '  Preparation  of  Instruments 
TioN  Sterilized  Water 

Disinfection  of  Hands  and  Fore-  Preparation  of  Operating  Room 
ARMS  Preparation  for  Operation  in  Pri- 

Preparation  of  Surgical  Utensils       vate  House 

Preparation  of  Gauze  and  Sutures  Operating  Bag 

Until  recent  years  the  principles  of  asepsis  in  surgery  were  little 
known  and  imperfectly  practised.  The  field  of  operation,  the  hands 
of  the  assistants  and  operators,  the  materials  used  in  the  operation — 
including  instruments,  suture  material,  gowns,  sponges,  dressings,  and 
solutions — were  not  perfectly  sterile. 

The  rendering  of  all  these  things  free  of  pathogenic  microorganisms 
constitutes  aseptic  surgery.  The  procedure  is  of  such  vital  importance 
that  a  detailed  recital  of  the  methods  of  sterilization  might  be  of 
interest,  but  the  details  are  so  varied  that  the  author  must  confine 
himself  to  a  description  of  those  methods  which  he  himself  employs. 
In  many  instances  they  are  no  better  than  others  elsewhere  in  vogue, 
but  space  will  not  permit  of  a  consideration  of  all  approved  methods. 

Sterilization  of  the  Field  of  Operation. — See  page  244. 

Disinfection  of  the  Hands  and  Forearms. — The  surgeon  and  his 
assistant  should  guard  against  the  contamination  of  their  hands  with 
septic  material.  They  should,  therefore,  not  engage  in  postmortem 
examinations  or  in  the  treatment  of  acute  infectious  diseases.  When 
operating  on  the  cadaver  or  on  septic  cases  the  hands  and  arms 
should  be  protected  by  long  rubber  gloves.  Failure  to  regard  such 
precautions  may  be  the  means  of  conveying  infection  to  the  field  of 
operation. 

In  disinfecting  the  hands  and  forearms  greater  importance  should 
be  attached  to  mechanical  than  to  chemical  disinfection.  Undue 
reliance  is  often  placed  upon  chemical  disinfection.  No  amount  of 
antiseptics  can  atone  for  laxity  in  the  use  of  the  scrub  brush.  A 
stiff  sterile  nail  brush  should  be  chosen,  and  should  be  of  sufficient 
size  to  permit  vigorous  usage.  The  author  is  in  the  habit  of  scrubbing 
his  hands  under  running  water  from  the  tap.  The  temperature  of  the 
water  should  be  as  hot  as  can  be  borne  comfortably  by  the  hands.  Green 
soap  is  preferred  to  all  others.  The  arms  should  be  scrubbed  to  the 
elbows,  and  special  care  should  be  directed  to  cleaning  the  inner  surfaces 
of  the  fingers  and  nails.  An  orange  stick  and  peroxide  of  hydrogen 
are  best  suited  for  cleaning  the  finger  nails.  Ten  minutes  should  be 
occupied  in  scrubbing.  The  arms  and  hands  are  then  thoroughly  rinsed 
in  sterile  water  and  dried  with  a  sterile  towel. 


DISINFECTION  OF  THE  HANDS  AND  FOREARMS  253 

An  assistant  pours  into  the  palms  of  the  hands  about  two  drams  of 
a  sokition  composed  of  eight  parts  of  creolin  and  two  of  glycerin.    This 

Fig.   126 


Scrubbing  of  hands.     The  nurse  pours  liquid  green  scap  on  the  hands  of  the  operator. 

Fig.   127 


Method  of  putting  on  dry  sterile  gloves.  Gloves  and  hands  are  powdered  with  sterile  talcum.  The 
assistant  holds  the  sleeve  of  the  glove  well  apart  while  the  operator  inserts  his  hands.  In  this  manner 
the  hand  does  not  touch  the  outside  of  the  glove. 


254 


PRINCIPLES  OF  ASEPSIS  IN  GYNECOLOGY 


solution  is  rubbed  into  the  hands  and  arms  for  five  minutes.  The  hands 
and  arms  are  then  washed  in  a  1  per  cent,  creohn  solution,  next  in 
sterile  w^ater,  and  finally  in  alcohol.  A  long  sleeve  gown  is  then  put 
on  and  the  hands  covered  with  sterile  rubber  gloves.  A  mouth-piece 
of  several  layers  of  sterile  gauze  should  cover  the  mouth  and  nose. 
One  objection  to  the  creolin  and  glycerin  solution  is  that  it  smarts 
the  arms.  This  can  be  largely  overcome  by  thoroughly  drying  the 
hands  and  forearms  before  applying  the  solution. 


Fig.   128 


Operator  prepared  for  operation. 


Preparation  of  Surgical  Utensils. — Brushes. — Small,  flabby  nail 
brushes  should  never  be  employed;  they  should  be  made  of  stiff  bristles, 
and  when  the  bristles  have  lost  their  stiffness  the  brushes  are  to  be  dis- 
carded. They  should  be  large  enough  to  afford  a  good  grasp,  but 
not  so  large  as  to  be  unwieldly.  Sterilization  of  the  brushes  should  be 
by  boiling,  preferably  in  water  containing  soda  bicarbonate.  Before 
taking  up  a  sterile  brush  to  scrub  the  hands,  they  should  be  first 
washed  with  soap  and  water,  otherwise  the  brush  will  become  unneces- 
sarily contaminated.  After  vigorous  scrubbing  with  the  brush  the 
author  completes  the  scrubbing  process  by  using  sterile  gauze  sponges, 
green  soap,  and  hot  sterile  water.  The  sponge  has  the  advantage  of 
not  roughening  the  hands. 


PREPARATION  OF  GAUZE  AND  SUTURES  255 

Basins. — Glass  or  porcelain-lined  basins  for  the  hand  solution, 
instruments,  sponges,  and  dressings  are  preferred,  though  agate-ware 
is  acceptable.  These  are  best  sterilized  by  putting  a  number  of  such 
clean  basins  in  a  pillow-slip  and  placing  them  in  a  steam  sterilizer. 
When  the  sterilizer  is  not  large  enough  to  accommodate  them  they 
may  be  boiled  in  a  wash-boiler.  For  hurried  sterilization  of  pans  and 
glass  vessels,  they  may  be  rinsed  with  pure  carbolic  acid,  then  with 
alcohol,  and  finally  with  sterile  water.  In  a  well-equipped  hospital 
a  utensil  sterilizer  is  of  the  greatest  convenience  and  utility. 

Rubber  Drainage  Pads. — A  Kelly  drainage  pad  is  indispensable  for 
carrying  away  solutions  while  preparing  a  patient  for  operations  and 
in  irrigating  during  operation.  The  Kelly  pad  is  cleansed  by  scrubbing 
with  soap  and  water,  followed  by  a  thorough  scrubbing  with  a  strong 
solution  of  lysol  or  creolin.    A  sterile  towel  is  then  placed  over  the  pad. 

Towels,  Bandages,  Gauze  Dressings,  Sponges,  and  Cotton. — These  are 
subjected  to  fractional  sterilization  in  a  steam  sterilizer,  first  for  one 
hour,  then  for  half  an  hour  on  two  successive  days.  If  not  used  for 
three  or  more  daj's  after  sterilizing  it  is  well  to  sterilize  them  again 
for  half  an  hour  on  the  day  of  the  operation.  All  towels,  sponges, 
and  dressings  should  be  wrapped  in  small  packages  and  counted  and 
labelled  before  being  placed  in  the  sterilizer. 

Preparation  of  Gauze  and  Sutures. — Iodoform  Gauze. — Sterile  gauze 
is  cut  in  desired  lengths  and  widths.  These  strips  are  then  saturated 
in  the  following  solution:  Warm  Castile  soapsuds,  6  ounces;  powdered 
iodoform,  1|  ounces.  After  thoroughly  mixing  the  solution  in  a  sterile 
basin  the  gauze  strips  are  saturated  by  rubbing  the  solution  into  the 
gauze.  The  strips  are  then  wrapped  in  small  packages,  labelled,  and 
placed  in  a  sterilizer  and  sterilized  on  three  successive  days.  In 
preparing  the  gauze  the  surgical  nurse  should  wear  sterile  gloves  and 
gown . 

Silk  and  Linen. — Surgical  silk  and  linen  are  best  sterilized  by  steam. 
The  silk  is  rolled  upon  glass  bobbins,  several  of  which  are  placed  in  an 
ignition  tube  with  a  cotton  stopper.  The  filled  tube  is  then  placed  in 
a  steam  sterilizer,  along  with  the  towels,  sheets,  and  sponges.  After 
sterilization  the  cotton  stopper  is  pushed  firmly  into  the  tube  and 
placed  in  a  glass  jar  to  await  its  use.  Frequent  sterilization  weakens 
silk  and  linen,  so  that  only  a  small  amount  should  be  placed  on  each 
bobbin.  The  most  serviceable  sizes  are  Nos.  2,  3,  and  4.  Twisted  silk 
is  preferred  to  the  braided.  The  author  has  found  little  need  for  silk 
and  linen  in  gynecological  practice.  Practically  the  only  places  where 
they  are  used  is  in  closing  the  abdominal  incision  where  the  abdominal 
wall  is  very  heavy  or  for  the  repair  of  a  postoperative  hernia.  In  such 
cases  two  to  four  stay  sutures  of  No.  3  twisted  silk  or  heavy  liiien  may 
be  passed  through  all  layers  except  the  peritoneum.  The  external 
sutures  of  a  perineorrhaphy  may  also  be  of  No.  2  or  3  twisted  silk,  the 
advantage  over  silkworm  gut  being  greater  comfort  for  the  patient. 

Catgut. — For  all  private  work  and  for  a  limited  amount  of  hospital 
work  the  surgeon  is  scarcely  justified  in  preparing  his  own  catgut.    It 


256  PRINCIPLES  OF  ASEPSIS  IN  GYNECOLOGY 

is  safer  to  rely  upon  the  established  firms,  such  as  Lea,  Van  Horn, 
Walters,  and  Lukins. 

When  an  operator  is  using  a  large  quantity  of  catgut  he  may,  for 
purposes  of  economy,  prepare  his  own  catgut.  The  methods  of  pre- 
paring catgut  are  too  numerous  to  mention.  The  author's  preference 
is  for  the  Bartlett  catgut,  which  is  prepared  as  follows: 

1 .  "  The  strands  are  cut  into  little  coils  about  as  large  as  a  silver 
quarter  of  a  dollar.  These  coils,  in  any  desired  number,  are  then  strung 
like  beads  on  to  a  thread,  so  that  the  whole  quantity  can  be  conveniently 
handled  by  simply  grasping  the  thread. 

2.  "The  string  of  the  catgut  coils  is  dried  for  one  hour  at  a  tem- 
perature of  180°  F.,  and  then  for  a  second  hour  at  220°  F.,  the  change 
of  temperature  being  gradually  a(5complished. 

3.  "The  catgut  is  placed  in  liquid  albolene,  where  it  is  allowed  to 
remain  until  perfectly  'clear,'  in  the  sense  that  the  term  is  used  in  the 
preparation  of  histological  specimens.  This  is  usually  accomplished  in 
a  few  hours,  though  it  has  been  my  custom  to  allow  the  catgut  to 
remain  in  the  oil  overnight. 

4.  "The  vessel  containing  the  oil  is  placed  upon  a  sand  bath  over- 
night and  the  temperature  raised  during  one  hour  to  320°  F.,  which 
temperature  is  maintained  for  a  second  hour. 

5.  "By  seizing  the  thread  with  a  sterile  forceps  the  catgut  is  lifted 
out  of  the  oil  and  placed  in  a  mixture  of  iodine  crystals,  1  part,  and 
Columbian  spirit  (deodorized  methyl  alcohol),  100  parts.  In  this  fluid 
it  is  stored  permanently,  and  is  ready  for  use  in  twenty-four  hours." 

The  advantages  of  Bartlett  catgut  are  its  strength,  elasticity,  and 
antiseptic  qualities. 

Silkworm  Gut. — The  preparation  of  silkworm  gut  is  like  that  of  silk. 
For  hurried  preparation  it  may  be  boiled  or  carbolized. 

Preparation  of  Instruments. — Simplicity  in  construction  is  an 
essential  quality  for  surgical  instruments.  All  irregularities  upon 
instruments  add  to  the  difficulties  in  cleansing,  and  should  be  dis- 
pensed with  as  far  as  possible. 

After  operating,  all  instruments  should  be  scrubbed  in  soap  and 
water,  rinsed  in  sterile  hot  water,  and  thoroughly  dried.  After  use  in 
septic  cases  instruments  should  be  boiled  before  being  dried.  No 
rusty  instruments  should  be  used  because  of  the  difficulty  in  sterilizing 
them. 

In  selecting  instruments  for  operation  the  operator  should  bear  in 
mind  the  possibility  of  having  to  meet  with  the  unexpected,  and  there- 
fore the  supply  of  instruments  must  be  liberal.  As  a  safeguard  it 
is  always  well  to  sterilize  all  instruments  needed  in  abdominal  and 
vaginal  operations  irrespective  of  the  probable  demands.  In  order 
that  no  instruments  be  overlooked  the  operator  should  select  his  own 
instruments  and  should  lay  them  in  the  tray  in  the  order  of  their 
expected  use.  For  example,  he  first  selects  the  knives,  then  the  hem- 
ostats  of  all  sizes,  next  the  tissue  forceps,  then  the  retractors,  scissors, 
pedicle   needles,  needle  holders,  tenacula,  needles,  etc.,  until  the  list 


PREPARATION  OF  OPERATING  ROOM  257 

is  complete.  There  should  always  be  at  least  two  knives,  two  scissosr, 
and  two  needle-holders,  in  case  one  should  drop  to  the  floor  or  in  any 
way  become  unserviceable. 

The  instruments  are  boiled  in  1  per  cent,  bicarbonate  of  soda  solution 
for  ten  minutes;  this  solution  should  completely  cover  the  instruments. 
In  order  to  preserve  the  cutting  edge,  all  scissors  and  knives  should  be 
sterilized  by  dipping  first  in  pure  carbolic  acid,  then  in  alcohol,  and 
finally  in  sterile  water.  The  sterilized  instruments  are  placed  in  glass 
trays  partly  filled  with  sterile  water,  or  may  be  laid  upon  a  sterile 
table  and  covered  with  a  sterile  sheet  or  towels. 

Sterilized  Water. — All  water  used  in  operations  should  be  first 
filtered  and  then  boiled  for  a  half  hour.  An  abundant  supply  of  sterilized 
water,  both  hot  and  cold,  should  always  be  at  hand. 

Preparation  of  Operating  Room. — In  the  construction  of  an  operating 
room,  utility  rather  than  useless  ornamentations  should  be  the  aim. 
Ornamentations  only  add  to  the  expense  and  to  the  labor  in  keeping 
the  room  in  order. 

The  essential  factors  in  the  construction  of  a  modern  operating 
room  are  good  light,  good  ventilation,  sufficient  space,  and  convenience. 
The  best  light  comes  either  through  the  north  side  or  through  a  sky- 
light sloping  to  the  north. 

Over  the  operating  table  should  be  an  electric  bracket,  with  a  group 
of  four  or  more  lights,  and  to  this  bracket  is  attached  a  portable  light 
with  a  reflector.  Gas  should  be  provided  as  a  substitute  in  case  the 
electricity  is  out  of  order.  The  ventilation  should  be  adequate  but 
of  the  simplest  construction.  No  currents  of  air  should  be  permitted 
to  come  in  contact  with  the  patient.  Whatever  the  material  used 
for  walls  and  floor  it  must  be  smooth  and  of  hard  finish.  While 
marble  is  durable  and  ornamental,  it  cannot  be  claimed  that  it  is 
more  serviceable  than  enamelling.  The  floors  may  be  of  tile,  mosaic, 
or  cement.  All  angles  should  be  rounded  to  facilitate  cleaning.  The 
dimensions  of  the  room  should  be  not  less  than  12  x  14,  and  the  ceiling 
not  less  than  ten  feet  high. 

A  well-appointed  operating  room  suite  will  consist  of  an  operating 
room,  sterilizing  room,  surgeons'  dressing  room,  with  shower  bath, 
appliance  room,  anesthetic  room,  and  recovery  rooms.  The  equipment 
of  the  operating  room  should  be  substantial  and  simple.  The  stationary 
basuis  for  washing  the  hands  should  be  three  or  four  in  number,  and 
should  be  provided  with  hot  and  cold  water  controlled  by  a  pedal 
attachment. 

No  sterilizers,  water-boilers,  receptacles  for  dressings  and  the  like 
should  be  in  the  operating  room. 

Warming  the  Operating  Table. — As  a  preventive  measure  to  shock 
in  cold  weather  the  operating  table  may  be  warmed  by  a  series  of 
electric  lights  fitted  to  a  frame  under  the  table.  Robb  has  devised  a 
series  of  electric  lamps  held  in  an  upright  position  by  attachments  to 
two  hollow,  movable  metal  tubes,  which  are  applied  to  the  under 
surface  of  the  table.  There  are  two  rows  of  thirty-two  candle-power 
17 


258  PRINCIPLES  OF  ASEPSIS  IN  GYNECOLOGY 

lamps,  each  of  nine  lamps.  The  amount  of  heat  is  controlled  by  a  series 
of  switches,  making  it  possible  to  turn  on  two  lamps  at  a  time  until 
the  desired  amount  of  heat  is  supplied.  The  apparatus  is  detachable 
and  can  be  used  wherever  there  are  electric  attachments. 

Fig.  129 


Showing  lamps  with  table  in  Trendelenburg  position.     (Eobb.) 
Fig.   130 


Showing  lamp  detached  from  operating  table.     (Robb.) 

Preparation  for  Operation  in  a  Private  House. — While  it  is  possible 
to  prepare  and  equip  an  operating  room  in  a  good  private  house  so 
that  the  principles  of  aseptic  surgery  can  be  carried  out,  it  is  always  at 
the  expenditure  of  much  time  and  labor. 

The  surgeon  naturally  feels  that  it  is  his  assistants  who  fail  to  adapt 
themselves  to  the  strange  and  more  or  less  improvised  surroundings, 
but,  as  a  matter  of  fact,  he  himself  is  not  so  much  the  master  of  the 
situation  as  when  in  his  own  operating  room  and  hospital. 

Frequently  the  needed  equipment  is  not  at  hand,  the  light  may  be 
faulty,  the  temperature  and  ventilation  of  the  room  not  properly 
regulated;  these  and  many  other  things  cause  him  annoyance.     The 


PREPARATION  FOR  OPERATION  IN  A  PRIVATE  HOUSE     259 

only  satisfactory  way  is  for  the  operator  to  take  with  him  his  own 
trained  assistants. 

Preparation  of  the  Room  for  Operation  in  the  Home. — In  preparing  a 
room  for  operation,  light,  space,  and  cleanliness  are  of  the  first  con- 
sideration. All  unnecessary  articles  are  to  be  removed.  The  floor 
and  all  wood-work  in  the  room  should  be  scrubbed  and  the  walls  and 
ceiling  wiped.  The  mattress  should  be  aired  and  covered  with  fresh 
linen,  underneath  which  should  be  placed  a  rubber  sheet.  Only  a  wet 
cloth  should  be  used  in  cleaning  the  room  on  the  morning  of  the  opera- 
tion, and  every  precaution  should  be  taken  to  prevent  dust  from  rising 
in  the  air.    Clean  sheets  mav  be  huns:  over  the  walls. 


Room  prepared  for  abdominal  operation  in  private  house. 

The  following  articles  should  be  provided  for  the  room:  a  common 
kitchen  table,  four  wooden  chairs,  a  dishpan,  a  foot  bathtub,  two 
water  buckets,  two  small  tables,  one  rubber  sheet  two  yards  long  by 
one  yard  wide,  a  bed-pan,  three  earthen  pitchers,  a  new  wash-boiler, 
several  quart  bottles  suitable  for  hot  water,  one  dozen  clean  towels  and 
two  clean  sheets,  and  four  wash-basins,  preferably  of  porcelain-lined 
granite-ware. 

A  trained  assistant  should  be  sent  the  day  before  the  operation  to 
make  all  needed  preparations.  When  the  time  is  short  the  attendant 
should  be  directed  to  scrub  a  new  wash-boiler  with  Sapolio,  to  rinse  it 
out  thoroughly,  and  then  to  fill  it  two-thirds  full  of  water  and  boil  for 


260 


PRINCIPLES  OF  ASEPSIS  IN  GYNECOLOGY 


an  hour.  The  water  should  be  boiled  two  hours  before  the  operation, 
and  without  removing  the  lid  it  should  be  allowed  to  cool  and  await 
the  coming  of  the  operator.  It  is  exasperating  to  be  compelled  to  wait 
for  water  to  cool. 

Upon  arriving  at  the  house  the  surgeon  should  inspect  everything 
to  satisfy  himself  that  all  is  as  it  should  be.  In  emergency  cases,  when 
there  has  not  been  time  to  take  up  the  carpets  the  day  before  the 
operation,  they  should  not  be  removed  for  fear  of  raising  the  dust; 
instead,  damp  sheets  may  be  placed  over  the  floor.  With  a  portable 
operating  table,  brought  by  the  surgeon,  it  is  possible  to  perform  any 
operation  without  serious  embarrassments. 

The  operator  must  exercise  great  vigilance  with  his  assistants  who 
may  not  be  able  to  accommodate  themselves  perfectly  to  strange 
environments  and  therebv  be  led  into  grave  errors  in  technic. 


Fig.   132 


Portable  combination  sterilizer  for  instruments  and  dressings. 


The  greatest  objection  that  can  be  offered  to  operating  in  houses 
is  the  necessity  of  leaving  the  after-care  of  the  patient  to  other  and 
often  inexperienced  hands.  This  is  most  unfortunate,  and  in  the  author's 
judgment  a  surgeon  is  justified  in  declining  to  accept  the  responsibility 
of  such  a  case  unless  it  be  an  emergency.  He  should  make  sure  that 
the  case  will  receive  skilled  after-treatment  or  decline  to  operate, 
unless,  as  has  been  said,  the  case  is  an  emergency  and  cannot  be  taken 
to  a  hospital. 

Operating  Bag. — The  surgeon  should  always  have  his  operating  bag 
in  readiness.  This  bag  should  contain  all  needed  instruments,  freshly 
sterilized  sheets,  towels,  pads,  sponges,  and  dressings.     Upon  arriving 


OPERATING  BAG  261 

at  the  house  all  that  is  needed  is  the  preparation  of  the  patient,  a  suit- 
able table,  an  abundance  of  sterile  water,  and  three  or  four  sterile  pans. 
These  things  should  be  attended  to  by  the  nurse  in  charge  before  the 
arrival  of  the  surgeon,  so  that  there  need  be  little  delay. 

Contents  of  a  Complete  Operating  Bag  for  Abdominal  Operations. — 

IxSTEriMEXTS  AXD  ACCESSORIES : 

Green  soap  in  compressible  tube  or  glass  jar. 
Four  nail  brushes. 

Creolin-glycerin  solution,  8  to  2  (four  ounces). 
Bichloride  of  mercury  tablets. 
Alcohol  (eight  ounces). 
Razor. 

Ether  (one  pound). 
Ether  mask. 

Hypodermic  syringe  and  strychnine,  1  to  40  tablets. 
Rubber  irrigating  bag  with  glass  nozzle. 
Four  rubber  sheets,  one  yard  square. 
Three  long  sleeve  aprons. 
Safety  pins  (one  dozen). 
Laparotomy  pads  (three  sizes). 
Sponges. 

Iodoform  gauze  (one  large  and  several  small  rolls). 
Dressings  of  sterile  gauze. 
Muslin  abdominal  binder. 
Surgical  Ixstruimexts,  Sutures,  and  Ligatures: 
Two  knives. 
Two  pairs  of  scissors. 
One  long  and  two  short  tissue  forceps. 
One  Simpson  abdominal  retractor. 
Two  Simon's  specula. 
One  dozen  six-inch  hemostats. 
Six  large  hemostat  forceps. 
Two  needle  holders. 
One  dozen  assorted  needles. 
Two  pedicle  needle  holders. 
Silkworm  gut. 
Silk,  sizes  2,  3,  and  4. 
Catgut,  sizes  1,  2,  .3,  both  plain  and  chromicized. 


CHAPTER  XV 

ANOMALIES  AND  MALFORMATIONS  OF  THE  GENITAL 

ORGANS 


Anomalies  and  Malformations  of 
THE  Vulva 

Absence  of  Vulva 

Double  Vulva 

Atresia  of  Vulva 

Infantile  Vulva 

Hypertrophy  of  Vulva 

Congenital  Anomalies  of  Clitoris 
Congenital  Fissures  of  the  Vulva 
Anatomy    and  .  Malformations     of 

THE  Hymen 
Anomalies  and  Malformations  of 
THE  Vagina 

Absence 

Atresia  and  Stenosis' 

Double  Vagina 

Blind  Pouches 


Anomalies  and  Malformations  of 

THE  Uterus 
Uterus  Deficiens 
Uterus  Rudimentarius 
Uterus  Foetalis 
Uterus  Unicornis 
Uterus  Septus 
Uterus  Bicornis 
Uterus  Didelphys 
Uterus  Accessorius 
Anomalies  and  Malformations  of 

THE  Fallopian  Tubes 
Anomalies  and  Malformations  of 

THE  Ovaries 
Absence  of  One  or  Both  Ovaries 
Congenital  Smallness  of  One  or 

both  Ovaries 
Supernumerary  Ovaries 
Congenital  Largeness  of  One  or 

both  Ovaries 


In  view  of  the  fact  that  malformations  and  maldevelopments  of 
the  genital  organs  commonly  present  a  multiplicity  of  deformities  in 
the  associated  organs,  it  will  be  easier  to  understand  the  subject  if  it 
is  considered  as  a  whole.  To  illustrate:  Absence  of  the  vagina  suggests 
the  probable  absence  of  the  uterus  and  its  appendages;  a  septum  of 
the  vagina  suggests  the  possible  presence  of  a  divided  uterus,  and  a 
uterus  of  the  infantile  type  suggests  the  almost  certain  presence  of 
underdeveloped  tubes  and  ovaries. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VULVA 

Absence  of  Vulva. — This  condition  is  rare,  and  is,  as  a  rule,  asso- 
ciated with  a  congenital  absence  of  the  internal  organs  of  generation. 
Absence  of  one  or  more  of  the  component  structures  of  the  vulva  is  not 
of  such  rare  occurrence,  and  may  be  found  associated  with  well-formed 
internal  organs  of  generation. 

Double  Vulva. — Double  vulva  is  an  extremely  rare  condition. 

Atresia  of  Vulva. — Atresia  of  the  vulva  may  be  found  associated 
with  a  communication  between  the  rectum,  bladder,  and  genital  canal. 
The  fetus  is  rarely  viable,  but  the  defect  may  be  found  in  mature  years. 

The  atresia  may  be  complete.  In  this  case  the  newborn  child  will 
be  unable  to  urinate  until  the  septum  is  divided.    As  a  rule  the  coales- 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VULVA        263 

cence  is  incomplete,  there  being  a  small  opening  through  which  the 
urine  and  menstrual  blood  escape  and  through  which  it  is  possible  for 
conception  to  take  place,  as  in  one  of  the  author's  cases. 

Treatment. — The  treatment  consists  in  passing  a  grooved  director 
through  the  opening  and  slitting  the  septum  vertically.  The  vulva 
is  then  lightly  packed  with  sterile  gauze  for  three  to  five  days. 

Fig.  133 


^J>arooplioron  or 
Nephric  pt.of 
Wolffian  Body. 


Uterus 


-■V.  Aberrans 
Paradidymis  or 
Nephric  pt.  of 
Wolffian  Body. 


Urethra 


III. 


Relationship  of  the  sexual  ducts  and  their  rudiments  in  the  two  sexes.     /,  the  indifferent  primary 
type;  //,  the  differentiation  in  the  female;  ///,  the  differentiation  in  the  male.     (Adami.) 

Infantile  Vulva. — The  infantile  type  of  the  vulva  may  be  maintained 
after  puberty.  The  entire  vulva,  or  one  or  more  of  the  component 
parts,  may  fail  to  mature  to  the  full  sexual  type.  Cretins  and  dwarfs 
mostly  retain  the  infantile  type.  The  vulva  may  mature  at  the  time 
of  puberty,  and  subsequently  undergo  atrophic  changes  involving  part 
or  all  of  the  vulva.  Such  atrophy  occurs  in  wasting  diseases  in  certain 
nervous  disorders,  such  as  epilepsy,  and  after  removal  of  the  ovaries. 
A  physiological  atrophy  occurs  after  the  menopause. 

Hypertrophy  of  the  Vulva. — Hypertrophy  of  the  vulva  rarely  involves 
all  structures  composing  the  vulva. 

Congenital  Anomalies  of  the  Clitoris. — The  clitoris  may  be  absent, 
bifid,  small,  or  large. 


264     AXOMALIES   AXD  MALFORMATIOXS  OF  GEXITAL   ORGAXS 

Absence. — This  is  a  rare  finding. 

Atrophy. — Less  rare  than  absence  is  a  congenital  hypoplasia  of  the 
clitoris. 

Hypertrophy. — The  clitoris  varies  in  size  within  normal  limits.  It 
has  attained  the  size  of  the  penis.  There  is  no  fomidation  for  the 
belief  that  masturbation  causes  the  clitoris  to  enlarge.  Syphilis  is 
named  as  a  causal  factor. 

Fig.   134 
mons  veneris 


MEATUS 
URiNARIUS 


Vulva  of  a  -virgiii.     The  labia  have  been  widely  separated.     (Testut.) 


Symytom^. — ^As  a  rule  no  symptoms  arise,  but  in  some  instances 
the  enlarged  clitoris  may  interfere  with  intercourse  and  may  cause  a 
deflection  of  the  stream  in  urinating.  At  times  it  causes  great  annoyance 
by  becoming  irritated. 

Treatment. — Xo  treatment  is  indicated  when  there  is  moderate 
enlargement.  ^Mien  there  is  great  hj-pertrophy  the  clitoris  should  be 
removed  by  a  wedge-shaped  incision  and  the  stump  closed  by  two  or 
more  interrupted  sutures  of  Xo.  1  chromic  catgut.  Irritation  of  the 
clitoris  is  relieved  by  rest,  the  application  of  oxide  of  zinc  ointment, 
or  lead  water  and  laudanum  lotion.    Sitz  baths  will  afford  relief.     . 

Adhesions  of  the  Prepuce. — ^The  prepuce  may  become  adherent  to 
the  clitoris  as  the  result  of  uncleanliness  and  inflammation.    It  is  not 


ANOMALIES  AND  MALFORMATIONS  OF   THE   VULVA        265 


uncommon  to  find  the  entire  glans  of 
the  clitoris  covered  by  an  adherent 
prepuce. 

Symptoms. — Local  irritation  leads  to 
sexual  abuses  and  morbid  sexual  de- 
sires. Some  maintain  that  a  long  train 
of  nervous  disturbances  is  engendered. 
When  the  sebaceous  material  accumu- 
lates under  the  prepuce,  local  tender- 
ness and  pain  may  result.  Wherever 
there  is  local  irritation  an  examination 
should  be  made. 

Treatment.  —  Grasp  the  clitoris  be- 
tween the  thumb  and  index  finger,  and 
make  backward  traction  upon  the 
clitoris.  If  the  adhesions  do  not  yield 
they  may  be  separated  by  a  dissector. 
It  may  be  necessary  to  apply  a  10  per 
cent,  solution  of  cocaine  before  under- 
taking the  procedure.  The  glans  is 
anointed  daily  with  carbolized  vaseline 
to  prevent  reformation  of  adhesions. 

Congenital  Fissures  of  the  Vulva. — 
Epispadias. — Epispadias  is  caused  by 
failure  of  closure  on  the  part  of  the 
anterior  abdominal  wall,  together  with 
a  dehiscence  of  the  anterior  wall  of 
the    allantois.      The    allantois    thus 


Fig.  135 


Adherent  labia.  The  vaginal  outlet  is  re- 
stored by  making  a  vertical  incision  along  the 
line  of  adhesion. 


Fig.   13S 


Fig.  137 


Hypertrophy  of  the  cUtoris. 


Amputation  of  hypertrophied  clitoris.  A 
wedge-shaped  incision  is  made  and  interrupted 
chromic  catgut  sutures  are  passed  from  side  to 
side.     (After  Ashton.) 


266     ANOMALIES  AXD  MALFORMATIOXS  OF  GENITAL  ORGANS 

communicates  with  the  outer  world.  The  defect,  if  possible,  should 
be  remedied  by  a  plastic  operation,  ^yhen  this  is  impossible  a  urinal 
must  be  adjusted  and  the  parts  kept  as  clean  as  possible. 


Fig.  138 


Fig.  139 


Adhesions  of  the  prepuce.  The  adhesions 
are  severed  by  a  dissecting  instrument. 
(After  Ashton.) 


Redundant  prepuce.  First  step.  The  prepuce 
is  severed  in  the  median  line  and  the  clitoris 
exposed. 


Fig.   140 


Adherent  prepuce.     Second  step.     Either  flap  of  the  prepuce  is  excised  with  scissors. 


Hypospadias. — Hypospadias  is  formed  by  a  persistence  of  the  uro- 
genital sinus.  The  urethra  and  vagina  open  high  up  in  the  vestibular 
canal.    The  perineum  is  well-developed.     The  urethra  may  be  absent 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VULVA        267 

and  the  bladder  communicate  directly  with  the  vagina.  When  there 
is  complete  control  of  the  urine  no  treatment  is  required,  but  otTierwise 
an  effort  should  be  made  to  separate  and  approximate  the  mucous 
membrane  of  the  urethra  with  sutures. 


Fig.   141 


Fig.  142 


Adherent    prepuce.      Fourth    step.      The 
Adherent  prepuce.     Third  step.     The   sutures  of  sutures  of  silkworm  gut  are  tied.     This  pro- 

silkworm  gut  are  in  place.  vides  free  exposure  of  the  clitoris. 


Fig.  143 


CRESCENTiC 


FRINGED 


BILABIAL  BIPERFORATE  CRIBRIFORM 


Different  forms  of  hymen.     (Testut.) 


Anatomy  and  Malformations  of  the  Hymen. — Physiological  rupture 
and  stretching  of  the  hymen  occur  from  sexual  intercourse  and  childbirth. 


268     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

It  is  possible  for  the  hymen  to  be  merely  stretched  in  admitting  the 
penis  or  in  the  passage  of  the  child. 

The  lacerations  occurring  from  the  first  coition  are  usually  radial, 
and  do  not  extend  to  the  base  of  the  hymen.     It  is  possible  for  the 


Fig.  144 


Fig.   145 


Hymen  after  coitus.     (Testut.) 


Hymen  after  parturition.     (Testut.) 


Fig.  144. — C,  clitoris;  PL,  nymphae;  U,  meatus  urinarius;  OF,  vaginal  orifice;  H,  hymen;  D,  rents 
in  hymen. 

Fig.  145. — U,  meatus  urinarius;  P,  nymphse;  CM,  carunculae  mjTtiformes;  Z,  portion  of  hymen 
detached  and  floating;  D,  a  tear  through  the  fourchette. 


Fig.   146 


Imperforate  hymen  with  hematocolpos. 


hymen  to  be  partly  torn  from  its  base 
without  tearing  its  free  margin.  As  a 
rule,  there  is  a  circular  opening.  After 
childbirth  the  hymen  iscompletel}^  severed 
in  many  places,  leaving  isolated  tags 
(carunculse  myrtiformes).  These  lacera- 
tions often  extend  into  the  vagina  and 
perineum. 

The  question  of  the  existence  or  absence 
of  a  hymen  is  of  medicolegal  importance. 
It  is  self-evident  that  the  hymen  is  not 
a  trustworthy  guide  in  judging  virginity. 
The  hymen  may  be  present  and  intact 
after  sexual  intercourse  and  even  after 
childbirth,  while,  on  the  other  hand,  it 
may  be  totally  wanting  or  but  partially 
developed  in  virgins.  It  is  possible  for  a 
lacerated  hymen  to  heal  so  perfectly  that 
no  evidence  of  a  previous  laceration  is 
visible. 

^lalformations  of  the  hymen  are  con- 
genital or  acquired.  These  malformations 
are  a  double  hymen,  one  beside  the  other, 
in  cases  of  double  vaginae  and  a  hymen 


ANOMALIES  AND  MALFORMATIONS  OF  THE  HYMEN       269 

imperforatus  in  connection  with  other  malformations  of  the  Miillerian 
tract.  Atresia  caused  by  an  imperforate  hymen  may  be  congenital  or 
acquired.  As  pointed  out  by  Gellhorn,  where  the  remainder  of  the 
genital  tract  is  well-formed  the  atresia  is  undoubtedly  acquired. 
Neugebauer  has  collected  from  the  literature  the  reports  of  about  1000 
cases  of  atresia  of  the  hymen.  In  about  one-half  of  this  number  the 
lesion  was  acquired,  and  in  about  one-third  of  the  cases  the  history 
gave  no  suggestion  of  the  cause,  whether  congenital  or  acquired. 
Acute  infectious  diseases  and  gonorrhea  are  responsible  for  the  greater 
number  of  acquired  atresias. 


Fig.  147 


Fig.  148 


Hymen  with  single  minute  opening. 


Hymen  with  two  minute  openings. 


When  the  hymen  presents  an  obstacle  to  intercourse  it  should  be 
dissected  away  with  scissors  and  the  raw  edges  closed  with  a  running 
catgut  suture. 

Cysts  of  the  Hymen. — Little  is  known  of  cysts  of  the  hymen.  Wenkel 
made  the  first  report  in  1883.  Palm  describes  a  cyst  of  the  hymen 
measuring  8  cm.  in  diameter.  The  average  diameter  is  about  1  cm. 
Many  do  not  exceed  1  mm.  in  diameter.    They  are  usually  congenital, 


270     ANOMALIES  AM)  MALFORMATIONS  OF  GENITAL  ORGANS 


Fig.   149 


though  the^'  max  not  be  observed  until  late  years.  One  or  more  cysts 
are  located  near  the  free  margin  of  the  hymen.  The  presence  ot  a 
variety  of  epithelium  lining  the  cyst  cavity  suggests  a  variety  ot  sources. 
As  a  rule,  the  epithelium  is  squamous  and  stratified,  but  is  occasionally 
cylindrical .  and  in  a  few  instances  endothelium  is  found.  The  origm 
of  the  c^•sts  of  the  h^•men  is  in  many  cases  the  epithelial  projections; 
these  projections  become  constricted  off,  and  form  the  epithelial  wall 
of  a  space  which  fills  with  serum.  A  few  cases  apparently  arise  from 
Gartner's  duct,  from  dilated  lymph  spaces,  and  from  retention  of  the 
secretions  of  sebaceous  glands. 

In  a  valued  original  communication  on  the  "  Anatomy,  1  athology, 
and  Development  of  the  Hymen,"  G.  Gellhorn^  presents  numerous 
lesions  of  the  hvmen  not  generally  recognized. 

Inflammations  of  the  hymen  are 
primary  or  secondary  to  vuh'itis  and 
vaginitis.  The  inflamed  hymen  is 
markedly  reddened  and  bleeds  easily. 
The  same  changes  aft'ect  the  remains 
of  the  hymen  (carunculse  myrtif  ormes) . 
Tumors  of  the  hymen  are  rare.  Gell- 
horn  finds  seventeen  cases  of  hymeneal 
cysts  in  the  literature,  two  cases  of 
polypi,  and  one  of  angioma.  Sanger 
reported  a  case  of  primary  sarcoma 
of  the  hymen.  As  yet  no  case  of 
primary  carcinoma  of  the  hymen  has 
been  reported. 


ANOMALIES  AND  MALFORMATIONS 
OF  THE  VAGINA 

Inasmuch  as  the  vagina  is  partly 
developed  from  the  ducts  of  INIiiller, 
developmental  failures,  analogous  to 
those  found  in  the  uterus  and  tubes, 
are  to  be  found  in  the  vagina.  There 
may  be  a  complete  absence  or  a  partial 
development  of  the  vagina;  the  ducts 
of  ^Nliiller  may  fail  to  coalesce,  giving 

rise  to  a  double  vagina;  the  ducts  of  Miiller  may  coalesce  but  fail  to 

be  absorbed,  leaving  a  partial  or  complete  septum,  dividing  the  vagina 

in  the  median  line. 

Absence  of  the  Vagina. — Absence  of  the  vagina  may  result  either 

from  failure  of    the   ducts  of   ]Muller   to    develop  or  from  complete 


Xormal  \ulva  with   congenital  absence  of 
vagina  and  uterus. 


atresia.     As  a  rule  the  entire  Miillerian  tract  fails  to  develop,  hence 


1  Amer.  Jour,  of  Obstet.,  August,  1904. 


PLATE    XIV 


Fig.   2 


Fig.  I. — Atresia  at  the  vulva  first  causes  distention  of  the  vagina,  producing 
hematocolpos.     (Sutton  and  Giles.) 

Fig.  2. — Atresia  at  the  vulva.  Hematotrachelos  has  followed  hematocolpos. 
(Sutton  and  Giles.) 


Fig.   3 


Fig.   4 


Fig.  3. — Atresia  of  the  vulva  has  caused  hematocolpos,  then  hematotrachelos, 
and  then  hematometra.      (Sutton  and  Giles.) 

Fig.  4. — Atresia  at  the  vulva.  In  addition  to  the  conditions  in  Fig.  3,  there  is 
added  hematosalpinx.     (Sutton  and  Giles.) 


Fig.  1 


PLATE    XV 


Fig.   2 


Fig.   3 


Fig.  I. ^Atresia  in  the  vagina  midway  between  the  vulva  and  the  os  externum, 
causing  hematocolpos  in  the  upper  half  of  the  vagina.     (Sutton  and  Giles.) 

Fig.  2. — Same  as  in  Pig.  i,  except  that  distention  of  the  whole  uterus  has 
followed  the  partial  hematocolpos.     (Sutton  and  Giles.) 

Fig.  3. — Atresia  of  the  os  externum,  producing  a  hematotrachelos.  Corpus  uteri 
not  yet  distended.     (Sutton  and  Giles.) 


Fig.  4. 


Fig.   S 


Fig.  4. — Atresia  of  the  os  internum,  producing  hematometra.  Fallopian  tubes 
may  become  distended  later.      (Sutton  and  Giles.) 

Fig.  5. — Atresia  of  the  vulva  on  one  side  of  a  double  uterus  and  vagina,  causing 
a  hematocolpos  on  the  affected  side.     (Sutton  and  Giles.) 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VAGINA       271 

the  absence  of  the  vagina,  uterus,  and  tubes.  The  appearance  of  the 
external  organs  of  generation  may  be  misleading  in  determining  the 
sex.  Part  or  all  of  the  vagina  may  be  found  wanting,  due  to  a  lack  of 
canalization  of  part  or  all  of  the  lower  segment  of  the  ducts  of  Miiller. 
Symptoms. — No  symptoms  arise  until  the  time  of  puberty.  At 
this  time  the  attention  of  the  mother  is  called  to  the  failure  of  the 
menses  to  appear.  If  the  upper  genitals  fail  to  develop,  the  only  com- 
plaint is  that  of  amenorrhea;  but  if  the  uterus,  tubes,  and  ovaries 
develop  to  the  stage  of  functional  activity  the  menstrual  blood  will 
accumulate  in  the  uterus  and  tubes,  and  give  rise  to  the  presence  of  a 

Fig.   150 


Incomplete  transverse  septum  of  the  vagina:    a,  septum;    b,  hymen. 

tumor  in  the  pelvis  as  outlined  in  Plates  XIV  and  XV.  On  examina- 
tion the  vagina  will  be  found  to  be  absent,  and  there  will  be  discovered 
a  fluctuating  tumor  above  the  pelvis  and  extending  down  into  the 
pelvis.  This  tumor  is  observed  to  increase  in  size  with  each  menstrual 
epoch.  Occasionally  the  absence  of  the  vagina  is  not  observed  until 
after  marriage. 

Treatment. — When  the  menstrual  molimina  are  not  experienced  no 
treatment  is  advised  unless  it  is  desired  to  make  an  artificial  vagina 
to  provide  for  sexual  intercourse — a  procedure  that  should  be  under- 
taken with  caution  because  of  its  many  failures.     When,  however, 


272     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

the  uterus,  tubes,  and  ovaries  are  developed  it  becomes  imperative 
to  provide  an  outlet  for  the  menstrual  blood. 

Making  an  Artificial  Vagina. — A  sound  is  placed  in  the  bladder  and 
the  indejc  finger  of  the  left  hand  is  inserted  into  the  rectum.  A  transverse 
incision  is  then  made  with  the  knife  immediately  in  front  of  the  anus. 
A  dissection  is  then  made  between  the  bladder  and  rectum,  with  fingers 
and  dissecting  scissors,  until  the  cervix  is  reached.  The  opening  is 
spread  widely  by  the  fingers  or  forceps  and  the  contained  blood  is 
washed  away  with  an  antiseptic  solution.  When  the  blood  does  not 
readily  escape  from  the  uterus  the  cervix  must  be  dilated  and  the 
uterus  irrigated.     The  utmost  caution  should  be  observed  to  prevent 


Fig.  151 


Fimbriated  extremity 
of  tube. 
/vr/a^  Fallopian  tube. 


'\\'<:*> 


Broad  ligament, 
upper  part 


Artery 
vein. 


Vagina,  anterior  wall. 


The  uterus  and  its  appendages.  Posterior  view.  The  parts  have  been  somewhat  displaced  from 
their  proper  position  in  the  preparation  of  the  specimen;  thus  the  right  ovary  has  been  rai.sed  above 
the  Fallopian  tube  and  the  fimbriated  extremities  of  the  tubes  have  been  turned  upward  and  outward. 
(From  a  preparation  in  the  Museum  of  the  Royal  College  of  Surgeons  of  England.) 


infection.  To  prevent  subsequent  contraction  and  obliteration  of 
the  newly  formed  channel  an  effort  should  be  made  to  transfer  a  flap 
of  skin  from  the  perineum  or  labia  to  the  walls  of  the  channel.  When 
this  fails  a  glass  plug  should  be  introduced  and  worn,  not  only  until 
healing  has  been  effected,  but  for  an  indefinite  time,  to  prevent  sub- 
sequent contraction.  Failure  to  provide  an  artificial  outlet  for  the 
menstrual  blood  calls  for  an  abdominal  supravaginal  hj^sterectomy, 
leaving  the  ovaries  in  situ. 

Atresia  and  Stenosis  of  the  Vagina. — As  a  rule,  atresia  of  the  vagina 
is  incomplete.  It  is  usually  the  lower  segment  that  is  closed.  In 
extreme  cases  only  a  fibrous  or  fibromuscular  band  is  found  between 
the  bladder  and  rectum.    Back  of  the  obstruction  the  menstrual  blood 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VAGINA       273 

collects  in  the  vagina  (hematocolpos) ;  in  the  uterus  (hematometra) ; 
in  the  tubes  (hematosalpinx),  and,  finally,  in  the  pelvis  (hematocele). 
The  obstructing  tissue  may  be  stretched  and  crowded  down,  appearing 
at  the  vulvar  outlet  as  a  dark  bluish-red  membrane.  The  retained 
blood  does  not  usually  coagulate,  but  becomes  dark  in  color. 

Etiology. — Atresia  of  the  vagina  may  be  congenital  or  acquired. 
It  may  be  difficult  to  determine  whether  the  malformation  is  developed 
in  intra-uterine  or  in  extra-uterine  life.  In  young  infants  a  vaginitis 
may  form  adhesions  of  the  vaginal  surfaces  without  giving  rise  to 
symptoms.  Whether  a  fetal  vaginitis  can  account  for  congenital 
atresia  of  the  vagina  has  not  been  demonstrated.  The  usual  cause 
of  stenosis  and  atresia  of  the  vagina,  occurring  during  the  period  of 
sexual  maturity,  is  trauma  incident  to  labor. 

In  the  postclimacteric  stage  an  adhesive  vaginitis  may  narrow  or 
obliterate  the  vagina.  Gonorrhea  is  the  usual  underlying  cause  of 
senile  vaginitis.  In  congenital  atresia  the  obstruction  is  most  often 
at  the  junction  of  the  middle  and  upper  thirds  of  the  vagina,  which 
is  the  lower  limit  of  the  JMiillerian  ducts.  In  the  acquired  form  the 
obstruction  is  usually  similarly  situated.  The  obstruction  may  be 
merely  a  half-moon  or  annular  ring,  a  partial  or  complete  septum  with 
perforations,  or  a  membrane  varying  in  thickness,  even  to  filling  the 
vagina  completely.  Two,  three,  and  even  four  atresic  points  have 
been  described. 

Diagnosis. — The  diagnosis  of  stenosis  and  atresia  of  the  vagina  should 
present  few  difficulties.  When  a  girl  at  the  time  of  puberty  fails  to 
menstruate,  but  suffers  from  pain  in  the  pelvis,  which  increases  in 
severity  at  the  time  of  each  monthly  period,  atresia  of  the  vagina  or 
cervix  is  suspected.  If,  in  addition,  a  pelvic  tumor  develops  and 
fluctuates  distinctly,  the  diagnosis  is  highly  probable,  but  must  be 
confirmed  by  a  vaginal  examination.  Vicarious  menstruation  rarely 
occurs.  In  an  attempt  to  make  a  digital  examination  of  the  vagina 
the  finger  will  meet  the  obstruction.  The  extent  of  the  closure  is  best 
determined  by  the  finger  in  the  rectum.  If  the  obstruction  lies  high 
in  the  vagina  and  does  not  bulge  downward  it  is  not  likely  that  there 
is  any  considerable  secretion  pent  up  above  the  point  of  obstruction 
(Fig.  152). 

Hematometra  is  not  easy  to  demonstrate,  because  of  difficulty 
in  palpating  the  elevated  uterus  through  the  rectum.  The  uterus 
usually  lies  near  the  median  line,  and  is  rounded,  tense,  possibly 
fluctuating,  and  somewhat  increased  in  size. 

Treatment. — When  the  narrowing  of  the  vagina  does  not  present 
an  obstruction  to  the  menstrual  flow  or  interfere  with  intercourse  no 
treatment  is  advised. 

Forcible  Stretching  tinder  Anesthesia.— This  will  suffice  to  remove 
some  of  the  partial  obstructions. 

Excision  and  Incision  of  Seyta. — Excision  of  septa  and  whipping  the 
raw  edges  with  a  continuous  catgut  suture,  or  the  making  of  a  crucial 
incision  through  the  septum  and  packing  the  vagina  with  iodoform 
18 


274     AXOMALIES  AXD  MALFORMATIOXS  OF  GEXITAL  ORGAXS 

gauze  for  three  days  are  the  usual  methods  employed,  ^^^len  there  is 
accumulated  blood  above  the  point  of  obstruction  the  operation  inust 
be  done  with  every  possible  sm-gical  precaution  to  prevent  infection. 


Fig.  152 


Vaginal  septum.    The  index  finger  inserted  into  the  urethra  and  the  thumb  into  the  rectum  are 
approximated,  and  by  so  doing  the  atresic  vagina  is  demonstrated. 


When  blood  has  accumulated  in  the  vagina  or  in  the  vagina  and 
uterus  the  field  of  operation  is  made  sterile,  an  incision  is  made  in  the 
septum  and  the  pent-up  blood  is  allowed  to  escape.  If  the  uterus  is 
distended  the  cervix  is  carefully  dUated  to  permit  the  escape  of  the 
blood.  After  the  blood  has  escaped,  both  the  vagina  and  uterus  are 
irrigated  with  an  antiseptic  solution,  notably  bichloride  of  mercury, 
1  to  2000,  and  this  is  followed  by  a  copious  irrigation  with  sterile 
normal  salt  solution.  The  vagina  is  then  loosely  packed  with  iodoform 
gauze.  The  gauze  is  removed  at  the  end  of  twenty-four  hours,  and 
afterward  the  vagina  is  irrigated  with  a  mild  antiseptic  solution  once 
or  twice  daily.  The  vulva  is  protected  at  aU  times  by  a  sterile  gauze 
pad  held  in  place  by  a  T-binder.  ^ATnen  the  tubes  are  distended 
great  caution  must  be  exercised  in  manipulating  the  uterus  for  fear  of 


ANOMALIES  AND  MALFORMATIONS  OF  THE  VAGINA       275 

rupturing  the  tubes.  Rest  should  be  enjoined,  and  if  signs  of  infection 
arise  an  ice-bag  should  be  applied  over  the  lower  abdomen. 

If  blood  has  escaped  into  the  free  pelvic  cavity  it  should  be  given 
time  for  absorption,  and  if  this  does  not  occur,  or  if  the  blood  becomes 
infected,  vaginal  drainage  should  be  established  through  an  opening 
into  the  cul-de-sac  of  Douglas. 

Double  Vagina. — Double  vagina  is  the  result  of  failure  on  the  part 
of  the  ]Miillerian  ducts  to  fuse  perfectly.  From  this  cause  a  septum 
divides  the  vagina  in  part  or  throughout.  The  vaginal  canals  usually 
lie  side  by  side,  the  septum  running  anteroposteriorly.  The  canals  may 
be  unequal  in  size.    The  septum  rarely  runs  transversely,  so  dividing 

Fig.  153 


Uterus  didelphys,  with  double  vagina. 


the  vagina  that  one  lies  in  front  of  the  other — this  can  only  be  accounted 
for  on  the  supposition  that  the  Miillerian  ducts  had  rotated  prior  to 
their  fusion.  All  degrees  of  development  may  be  observed  in  the 
septum,  from  a  slight  ridge  to  a  complete  partition  composed  of  fibrous 
tissue,  mingled  with  seme  muscle  fibers  and  covered  on  either  side  with 
mucous  membrane.  The  cervix  and  uterine  body  are  usually  divided. 
If  both  canals  are  pervious  no  symptoms  need  arise  until  labor,  when 
there  may  be  an  obstruction  to  the  passage  of  the  child. 

No  treatment  is  advised  unless  the  septum  interferes  with  intercourse 
or  with  childbearing.  In  either  event  the  septum  should  be  excised 
with  scissors  and  the  raw  edges  stitched  with  a  continuous  suture  of 
catgut,  after  which  the  vagina  is  packed  loosely  with  iodoform  gauze 
for  one  or  two  days. 


276     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

BUnd  Pouches. — Pouches,  varying  in  size  to  an  inch  in  length,  are 
rarely  formed  in  the  lateral  walls  of  the  vagina.  These  pouches  may 
serve  as  a  receptacle  of  infection,  and  in  this  event  it  may  be  necessary 
to  open  them  up  freely  to  provide  drainage. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  UTERUS 

The  anomalies  and  malformations  of  the  uterus  are  classified  according 
to  their  origin  as  follows: 

I.  Those  Due  to  Imperfect  Development  of  Mijller's  Duct: 

1.  Uterus  deficiens. 
j^^^    [    2.  Uterus   rudimentarius. 
I    i    I    3.  Uterus  fetalis  (infantile  uterus). 

4.  Uterus  unicornis. 
II.  Those  Due  to  Imperfect  Blending  of  Muller's  Ducts: 

1.  Uterus  septus  (bilocularis). 

2.  Uterus  bicornis. 

3.  Uterus  didelphys  (uterus  duplex,  uterus  separatus). 

4.  Uterus  accessorius. 

Uterus  Deficiens. — It  is  very  unusual  to  find  a  complete  absence  of 
the  uterus  in  an  adult.  When  found  there  is  usually  also  an  absence 
of  the  entire  genital  tract,  or  only  a  rudimentary  development  of  the 
vulva,  vagina,  tubes,  and  ovaries.  The  round  ligaments  may  be  present, 
though  poorly  developed.  If  the  ovaries  are  present  the  menstrual 
molimina  will  be  experienced,  and  vicarious  menstruation  may  occur. 
There  may  or  may  not  be  sexual  desire. 

It  has  been  found  in  such  malformations  as  acephalia,  but  to  find 
no  trace  of  the  uterus  in  viable  fetuses  or  adults  is  indeed  rare.  A 
bilobed  uterus  has  been  mistaken  in  postmortem  examinations  for  the 
Fallopian  tubes,  and  a  hollow  rudimentary  uterus  for  the  vagina. 

There  may  be  no  evidence  of  a  uterus  other  than  a  thickening  of 
the  posterior  vesical  wall,  or  a  smooth  band  continuous  above  with 
the  tubes  and  below  with  the  round  ligaments,  or  the  broad  ligaments 
may  be  thickened  in  places  by  uterine  tissue.  It  is  manifestly  impossible 
to  make  a  clinical  distinction  between  such  rudimentary  conditions 
and  complete  absence  of  the  uterus.  Mistakes  have  been  made  in 
anatomical  dissections. 

The  ovaries  are  often  normal.  In  fact,  the  general  psychical  and 
physical  development  is  usually  perfect.  Periodic  ovulation  seldom 
occurs.  A  scanty,  bloody  discharge  occasionally  comes  from  the  vagina, 
but  has  not  been  demonstrated  to  be  a  menstrual  flow.  Vicarious  hem- 
orrhages from  the  nose  and  rectum  have  been  reported. 

The  condition  is  usually  recognized  in  the  eftort  to  determine  the 
cause  of  amenorrhea  and  sterility.  The  examination  is  best  made  per 
rectum.  A  sound  placed  in  the  bladder  can  be  palpated  along  its 
entire  course  within  the  bladder  by  the  finger  in  the  rectum.  If  the 
uterus  were  well  developed  this  would  be  impossible. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  UTERUS      277 

Fig.   1.54 


Uterus  didelphys  with  double  vagina. 


Fig.   155 


Uterus  bicornis  bicollis. 


Fig.   156 


Fig.  157 


Uterus  unicornis. 


Uterus  septale. 


278     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

Fig.  158 


Uterus  subseptate  bicollis. 


Fig.  159 


Uterus  bicornis  unicollis. 


Fig.  160 


Uterus  subseptate. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  UTERUS      279 

The  differential  diagnosis  between  a  complete  absence  of  the  uterus 
and  a  rudimentary  uterus  is  scarcely  possible  without  making  an  explor- 
atory incision.  Placing  a  sound  within  the  bladder  and  directing  an 
assistant  to  hold  it  while  proceeding  with  a  recto-abdominal"  exami- 
nation will  demonstrate  either  an  entire  absence  or  a  rudimentary 
development  of  the  uterus  (Fig.  162). 

Uterus  Eudimentarius. — As  the  name  imphes,  the  uterus  is  rudi- 
mentary in  its  development.  It  remains  as  a  fibromuscular  body,  ill 
formed  and  undersized.  The  walls  may  be  so  thin  as  to  suggest  the 
name  uterus  membranaceus.  The  cervix,  adnexee,  ligaments,  and 
vagina  are  likewise  rudimentary  or  absent.  The  external  genitals 
may  be  well-formed,  though  this  is  not  probable.  As  already  stated, 
a  diagnosis  cannot  be  made  from  complete  absence  of  the  uterus  unless 
by  abdominal  section. 

Fig.  161 


Uterus  incudiformis. 

Uterus  Foetalis  (Infantile  Uterus). — The  uterus  and  adnexse  remain 
like  those  of  fetal  life  or  early  infancy — they  are  undersized.  No  sharp 
distinction  can  be  made  in  these  cases.  In  general  it  may  be  stated 
that  a  uterus  is  infantile  when  the  cervix  is  larger  than  the  corpus 
uteri,  the  walls  thin,  and  the  long  axis  of  the  uterus  less  than  two  inches. 
A  better  term  would  be  hypoplasia  uteri.  Aside  from  the  size,  the 
most  striking  feature  of  the  fetal  or  infant  uterus  is  the  disproportion 
between  the  cervix  and  the  body  of  the  uterus.  The  cervix  is  two- 
thirds  the  length  of  the  whole  organ,  the  body  one-third.  In  the  mature 
uterus  the  cervix  is  one-third  the  length  of  the  whole  organ,  the  body 
two-thirds.  Again,  the  arbor  vitae  in  the  fetal  or  infantile  uterus  extend 
the  entire  length  of  the  uterine  cavity,  while  in  the  adult  uterus  the 
mucosa  of  the  body  is  smooth  and  the  arbor  vitse  extend  only  the  length 
of  the  cervix.  Still  another  feature  of  the  fetal  or  infantile  uterus  is  the 
absence  of  a  fundus;  the  top  of  the  uterus  is  either  flat  or  depressed, 
while  in  the  adult  uterus  it  is  convex. 


280     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

The  vagina  is  usually  shorter  and  narrower  than  is  normal,  but,  as 
a  rule,  it  is  well  formed.  The  vulva  may  be  poorly  developed  and  the 
breasts  likewise,  but  this  is  not  the  rule. 

A  general  hypoplasia  of  the  whole  cardiovascular  system  is  said 
to  be  an  underlying  factor  in  this  developmental  failure.  Chlorosis, 
scrofula,  and  the  general  wasting  diseases  are  given  as  general  pre- 
disposing causes.  No  general  cause  can  account  for  local  hypoplasia 
when  the  other  structures  of  the  body  are  well  developed.  Cretins 
and  dwarfs  commonly  possess  fetal  or  infantile  uteri,  but  not  infre- 
quently there  is  perfect  general  physical  development.  It  is  probable 
that  the  developmental  failure  lies  primarily  in  the  ovaries. 

Fig.   162 


a,  ribbon-shaped  rudiment  of  the  uterus;  b,  b,  round  ligaments;  c,  c,  Fallopian  tubes;  d,  d,  ovaries. 

(Mann.) 


The  clinical  diagnosis  is  not  difficult.  Primary  amenorrhea  should 
always  suggest  the  probable  existence  of  an  infantile  uterus.  Sterility 
is  invariably  present.  If  the  patient  has  menstruated  normally,  or  if 
she  has  ever  been  pregnant,  there  is  no  possibility  of  an  infantile  or 
fetal  uterus.  A  small  vagina  and  vaginal  portion  of  the  cervix  suggest 
a  small  uterus.  A  recto-abdominal  examination  under  anesthesia  is 
preferred.  When  the  uterine  canal  will  admit  a  sound  the  measure- 
ment of  the  length  of  the  uterus  may  be  made,  and  an  estimate  of  the 
thickness  of  the  wall  can  be  arrived  at  by  a  conjoined  recto-abdominal 
examination,  the  sound  remaining  in  the  uterus. 

Uterus  Unicornis. — Only  a  single  horn  of  the  uterus  is  developed; 
the  opposite  horn  is  either  absent  or  rudimentary^ 


ANOMALIES  AND  MALFORMATIONS  OF  THE  UTERUS      281 

The  explanation  of  this  defect  hes  either  in  a  partial  or  complete 
failure  of  one  Miillerian  duct  to  develop.  The  single  horn  tapers  off 
into  the  tube.     At  the  juncture  of  the  horn  and  the  tube  the  round 

Fig.   163 


Uterus  unicornis:    LH,  left  horn;  LT,  left  tube;  Lo,  left  ovary;  RH,  right  horn;  RT,  right  tube; 
Ro,  right  ovary;  RLr,  right  round  ligament;  LLr,  left  round  ligament.     (Mann.) 


Uterus  septus  duplex  (natural  size),  completely  double  uterus,  and  incompletely  double  vagma  of 
a  girl,  aged  twenty-two  years:  a,  a,  tubes;  b,  b,  fundus  of  the  double  uterus;  c,  c,  c,  partition  of  uterus; 
d,  d,  cavities  of  the  uterine  bodies;  e,  e,  internal  orifices;  /,  /,  external  walls  of  the  two  necks;  g,  g, 
external  orifices;  h,  h,  vaginal  canals;  i,  partition  which  divided  the  upper  third  of  the  vagma  mto 
two  halves.     (Mann.) 


282     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

ligament  is  given  off.  There  is  no  fundus.  The  vagina  and  cervix 
are  small,  and  may  be  divided  partially  or  completely  by  a  septum. 
The  ovaries  and  tubes  may  be  rudimentary  or  absent;  so,  also,  the 
bladder  and  kidney  may  be  undeveloped,  or  there  may  be  absence  of 
the  kidney  on  the  side  opposite  the  single  horn.  The  cervix  is  small 
and  the  virgin  vagina  is  narrow.  The  deformity  is  difficult  to  distinguish 
clinically  from  the  infantile  uterus.  The  lateral  deflection  of  the  uterus 
is  highly  suggestive. 

Sterility  is  the  rule,  though  pregnancy  in  a  rudimentary  horn  is 
possible.  Amenorrhea  is  common,  but  the  menstrual  functions  may 
proceed  regularly.  When  pregnancy  exists  in  a  rudimentary  horn  the 
condition  is  not  unlike  tubal  pregnancy  in  its  chnical  aspect.  The 
dangers  of  rupture  and  of  hemorrhage  are  the  same.  There  is  no  way 
of  making  a  distinction  between  these  two  conditions  save  by  abdominal 
section,  unless,  as  is  possible  in  exceptional  cases,  the  gestation  sac  is 
demonstrated  by  abdominal  palpation  to  lie  within  the  attachment  of 
the  round  ligament.  In  tubal  pregnancy  the  gestation  sac  lies  external 
to  the  attachment  of  the  round  ligament. 

Utenas  Septus  (Bilocularis). — The  uterus  is  divided  by  a  vertical 
septum,  extending  a  variable  distance  from  the  external  os  to  the  fundus. 
On  the  exterior  there  is  no  evidence  of  a  septum.  The  uterus  is  broader 
and  more  globular  than  is  the  perfectly  developed  organ.  Not  infre- 
quently the  vagina  is  septate.  Various  explanatory  terms  have  been 
applied  to  the  several  degrees  of  the  septate  uterus — i.  e.,  uterus  biforis 
supra  simplex,  where  the  septum  is  only  found  near  the  external  os; 
uterus  subseptus  unicorporens,  where  the  septum  is  found  in  only  a 
part  of  the  cervix  and  body;  uterus  subseptus  unicellis,  where  the 
septum  is  found  in  the  body,  not  in  the  cervix;  and  uterus  subseptus 
uniforis,  where  the  septum  completely  divides  the  body  and  cervix, 
there  being  a  single  external  os. 

Uterus  Bicornis. — The  two  horns  of  the  uterus  are  united  to  a  limited 
and  variable  degree,  the  union  taking  place  from  below  upward.  The 
two  halves  of  the  uterus  are  rarely  developed  equally.  All  gradations 
are  observed  between  the  uterus  unicornis  with  a  rudimentary  second 
horn  and  the  uterus  bicornis  with  both  horns  fully  developed.  The 
tubes  and  ovaries  are  usually  normal,  but  the  vagina  often  participates 
in  the  duplexity.  The  degree  of  separation  varies  from  completely 
divided  bodies  with  a  single  cervix  to  a  union  of  the  two  horns,  leaving 
but  a  notch  in  the  fundus.  The  two  horns  are  not  always  of  equal 
size,  and  may  not  lie  on  the  same  plane.  A  septum  may  partially  or 
completely  divide  the  cervix  and  vagina.  One  or  both  horns  may  be 
imperforate.     The  external  genitals  are  usually  normal  (Fig.  166). 

In  addition  to  this  and  other  anomalies  in  the  development  of  the 
genital  organs  there  may  be  maldevelopments  of  the  urinary  tract — e.  g., 
ectopia  vesicae — and  absence  of  or  congenital  atrophy  of  the  kidney. 

The  behavior  of  a  uterus  bicornis  is  similar  to  that  of  the  uterus 
septus.  Menstrual  disorders  are  common.  Amenorrhea  may  result 
from  atresia  of  the  lower  genital  tract,  or  from  an  imperforate  lumen 


ANOMALIES  AND  MALFORMATIONS  OF  THE  UTERUS      283 

in  both  horns  of  the  uterus.  The  menses  may  flow  simultaneously 
from  the  two  horns  or  alternately  at  intervals  of  from  two  to  four  weeks. 
When  one  horn  or  one-half  of  a  septate  uterus  is  pregnant  the  opposite 

Fig.  165 


Septate  uterus.     Left  side  recently  contained  a  full-term  fetus.      Sketch  of  postmortem  specimen. 

Fig.  166 


Bicornate  uterus  with  bilateral  tuboovarian  abscesses.  The  specimen  was  removed  post  mortem. 
The  patient  refused  operation  and  died  of  general  suppurative  peritonitis.  Four  children  had  been 
born,  probably  from  the  larger  horn. 


284     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

side  may  continue  to  menstruate  or  may  become  pregnant  at  any  time 
during  the  period  of  gestation  in  the  other  side.    A  decidua  may  form 

Fig.   167 


Uterus  bicornis  unicellis:    a,  vagina  laid  open;  h,  single  cervix;  c,  c,  uterine  horns;  /,  /,  round  ligaments; 
d,  d.  Fallopian  tubes;  e,  e,  ovaries.     (Mann.) 


Fig.   168 


•  CI 

r 

Double  uterus  (uterus  didelphys):  a,  right  cavit)';  b,  left  cavity;  c,  right  ovary;  d,  right  round 
ligament;  e,  left  round  Ugament;  /,  left  tube;  g,  left  vaginal  portion;  h,  right  vaginal  portion;  i,  right 
vagina;  j,  left  vagina;  k,  partition  between  the  two  vaginae.     (Mann.) 

in  the  non-gravid  side  and  be  discharged  at  labor.  Pregnancy  and 
labor  may  progress  normally,  and  uterine  contractions  occur  in  both 
horns.     This,  however,  is  not  the  rule.    The  uterine  contractions  are 


ANOMALIES  AND  MALFORMATIONS  OF   THE   UTERUS      285 

seldom  regular  and  strong;  malpositions  and  malpresentations  of  the 
child  are  common;  placenta  prsevia  and  premature  detachment  of  the 
placenta  may  occur  at  any  time,  and  rupture  of  the  uterus  during 
labor  is  alwavs  to   be  feared. 


Fig.  169 


Uterus  didelphys,  sho-ndng  the  two  cer-\-ices  presenting  in  the  vaginal  vaults. 


The  presence  of  a  uterus  bicornis  or  uterus  septus  is  often  not  sus- 
pected, even  after  marriage  and  childbirth.  A  double  vagina  or  a  double 
cervix  will  suggest  the  presence  of  a  septate  or  bicornate  uterus.  When 
pregnancy  does  not  exist  the  finger  or  sound  will  aid  in  the  diagnosis. 
Under  anesthesia  the  separate  horn  may  be  detected  by  bimanual 
examination.  Invohition  is  rarely  as  perfect  in  the  puerperium  as  in 
the  normal  uterus,  and  displacements  and  subinvolution  are  liable  to 
develop  with  all  their  remote  consequences.  Placental  tissue  is  likely 
to  be  retained  in  the  uterus  and  lead  to  infection  and  hemorrhage. 


286     ANOMALIES  AND  MALFORMATIONS  OF  GENITAL  ORGANS 

Uterus  Didelphys  (Uterus  Duplex,  Uterus  Separatus). — Not  only 
tbe  uterine  horns  but  the  cervix  as  well  is  completely  divided.  Each 
half  is  equipped  with  a  single  tube,  ovary,  and  round  ligament.  The 
vagina  may  be  single,  double,  or  partially  divided.  The  two  halves 
may  be  in  different  planes  and  of  unequal  size.  One  or  both  sides  may 
be  imperforate.  All  that  has  been  said  of  the  clinical  features  of  a 
bicornate  uterus  will  apply  to  a  uterus  didelphys. 

Uterus  Accessorius. — This  is  the  rarest  of  anomalies  in  the  develop- 
ment of  the  uterus.  Hollander  and  Skene  each  observed  a  case  in 
which  a  small  uterus  was  situated  in  front  of  a  normal  uterus,  the  two 
bodies  joined  at  the  internal  os.  The  accessory  uterus  had  no  adnexse 
and  no  round  ligaments.  The  probable  explanation  of  this  anomaly  is 
that  a  diverticulum  of  Miiller's  duct  developed  into  an  accessory  uterus. 
In  Hollander's  case  the  patient  gave  birth  to  seven  children.  In  an 
abdominal  section  placental  tissue  was  found  in  the  accessory  uterus. 
In  Skene's  case  there  was  a  leucorrheal  discharge  from  the  accessory 
organ. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  FALLOPIAN 

TUBES 

1.  Both  tubes  may  be  wanting,  in  which  case  the  uterus  is  commonly 
absent. 

2.  A  single  tube  may  be  wanting,  in  which  case  the  corresponding 
side  of  the  uterus  is  usually  absent. 

3.  One  or  both  tubes  may  be  rudimentary  and  associated  with  a 
rudimentary  uterus.  The  tubes  may  remain  infantile  in  type,  very 
greatly  convoluted,  and  have  a  small  lumen. 

4.  The  lumen  of  the  tube  may  be  partially  or  completely  obliterated 
or  may  be  abnormally  large. 

5.  Rudimentary  tubes  or  fimbriae  may  spring  from  the  main  tube. 
Leading  into  the  main  tube  through  the  accessory  tubes  and  fimbriae 
are  rudimentary  canals  and  ostia. 

Webster  resected  the  fimbriated  end  of  a  tube;  some  months  later 
the  abdominal  cavity  was  again  opened  and  the  fimbriae  were  found 
to  be  regenerated. 

6.  Diverticula  of  the  endosalpinx  are  sometimes  present,  and  are 
known  to  be  a  cause  of  tubal  pregnancy. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  OVARIES 

Absence  of  One  or  both  Ovaries. — This  may  occur  as  a  congenital 
defect,  or  the  entire  ovarian  tissue  may  be  completely  lost  through 
the  development  of  atrophic  changes  or  new-formations.  When  both 
ovaries  are  absent  the  uterus  and  tubes  are  either  altogether  wanting 
or  poorly  developed.    Menstruation  and  childbearing  are  impossible. 


ANOMALIES  AND  MALFORMATIONS  OF  THE  OVARIES      287 

In  a  case  reported  by  Quain  there  was  vicarious  menstruation  from 
the  nose.  Two  of  Martin's  cases  were  sexual  perverts:  one  a  nympho- 
maniac, the  other  a  prostitute.  Martin  collected  twenty-two  cases  of 
congenital  absence  of  one  ovary.  In  one  of  his  cases  the  uterus  was 
normal,  but  the  right  tube  and  ovary  were  absent.  In  another  the 
uterus  and  vagina  were  rudimentary,  and  the  left  tube  and  ovary 
absent.  In  nine  of  the  twenty-two  cases  there  was  a  uterus  unicornis. 
The  vagina  and  vulva  are  seldom  influenced  by  the  absence  of  a  single 
ovary,  and  may  be  well-formed  when  both  ovaries  are  absent.  Torsion 
of  the  tube  or  adhesions  surrounding  the  tube  and  ovary  may  shut  off 
the  blood-supply  and  cause  complete  atrophy  of  the  ovary.  The  diag- 
nosis of  the  absence  of  one  or  both  ovaries  can  only  be  made  by 
inspection  after  the  abdomen  is  opened. 

Congenital  Smallness  of  One  or  both  Ovaries. — This  condition  may 
be  primary  or  secondary.  Martin  reports  thirty-six  cases  of  rudi- 
mentary ovaries;  none  menstruated,  and  only  seven  experienced  the 
molimina.  Twelve  of  the  thirty-six  had  a  rudimentary  vagina,  and 
in  every  case  the  uterus  was  under  size.  Rudimentary  ovaries  have 
been  recognized  by  a  conjoined  examination,  though  this  is  exceptional. 

Supernumerary  Ovaries. — Supernumerary  ovaries  are  accounted  for 
either  as  an  acquired  segmentation  of  the  ovary  or  as  a  congenital 
defect.  In  500  cases  supernumerary  ovaries  were  found  eighteen  times 
by  von  Wenkel.  Sanger  reported  one  that  measured  1  cm.  by  0.04  cm.; 
as  a  rule,  they  are  much  smaller.  Pregnancy  following  the  removal 
of  both  ovaries  is  explained  by  the  presence  of  a  supernumerary  ovary. 
A  true  supernumerary  ovary  is  rarely  found,  but  an  accessory  ovary 
constricted  ofP  by  adhesions  is  a  comparatively  frequent  lesion.  These 
accessory  ovaries  may  be  connected  with  the  ovary  by  a  pedicle  or 
be  completely  isolated.  Small  pedunculated  bodies,  resembling  ovarian 
tissue,  are  frequently  seen  near  the  ovaries;  these  are  detached  tubes 
of  the  parovarium,  small  myomata  of  the  ovarian  ligament,  or  stalked 
corpora  fibrosa.  The  clinical  significance  of  supernumerary  ovaries  is 
in  the  continuation  of  the  menstrual  and  childbearing  functions  after 
the  removal  of  both  ovaries.  The  diagnosis  can  only  be  made  by  direct 
inspection. 

Congenital  Largeness  of  One  or  both  Ovaries. — This  anomaly  is 
occasionally  found  associated  with  precocious  development  of  the 
sexual  organs.  Hypertrophy  of  the  ovary  is  more  often  an  acquired 
lesion.  It  is  physiological  during  pregnancy  and  is  commonly  associated 
with  uterine  fibroids.  It  must  be  remembered  that  the  normal  ovary 
varies  in  size  within  Mnde  limits. 


CHAPTER   XVI 


MALPOSITIONS  OF  THE   GENITAL  ORGANS 


Malpositions  of  the  Vaginal  Walls 

Normal  Position 

Cystocele 

Pectocele 

Vaginal  Hernia 
Malpositions  of  the  Uterus 

Normal  Position 

Pathological  Mobility 

Pathological  Fixation 

Anteposition 

Retroposition 

Lateroposition 

Elevatio  Uteri 

Torsion 

Prolapsus  Uteri 


Prolapse  of  Pregnant  Uterus 

Inversion 

Anteversion 

Anteflexion 

Retro  versioflexion 

Hernia 
Malpositions     of     the     Fallopian 
Tubes 

Normal  Position 

Changes  in  Position 
Malpositions  of  the  Ovaries 

Normal  Position  and  Histology 

Changes  in  Position 

Descensus  Ovarii 
Hernia  of  Tul^e  and  Ovary 


MALPOSITIONS  OF  THE  VAGINAL  WALLS 


Displacements  of  the  uterus  are  commonly  associated  with  displace- 
ments of  the  vaginal  walls  and  the  appendages  of  the  uterus;  hence  the 
advisability  of  presenting  the  subject  of  malpositions  of  the  genital 
organs  in  its  entirety. 

Cystocele. — Synonyms. — Relaxation  or  prolapse  of  the  anterior  wall 
of  the  vagina;  prolapse  of  the  bladder;  vesicovaginal  hernia. 

Etiology. — 1.  Relaxation  of  the  anterior  and  posterior  segment  of 
the  pelvic  floor,  due  to  labor. 

2.  Lacerations  of  the  anterior  and  posterior  segment  of  the  pelvic 
floor,  due  to  labor. 

3.  Prolapse  of  the  uterus. 

4.  General  malnutrition  wdth  loss  of  muscular  tone. 

5.  Violent  muscular  exertion. 

Cystocele  is  occasionally  observed  in  women  and  girls  who  have  not 
borne  children,  and  may  be  caused  by  a  lack  of  muscular  tone  and  by 
violent  muscular  exertion.  In  many  instances,  childbearing,  with 
the  resultant  stretching  and  tearing  of  the  anterior  and  posterior  seg- 
ments of  the  pelvic  floor,  is  the  underlying  cause  for  the  development 
of  cystocele.  The  lesion  is  very  common,  and  its  clinical  importance 
has  been  greatly  underrated. 

Anatomy. — The  bladder,  which  is  firmly  adhered  to  the  anterior 
wall  of  the  vagina,  will  inevitably  descend  w'th  the  vagina.    This  gives 


MALPOSITIONS  OF  THE  VAGINAL  WALL 


289 


rise  to  a  pouch  formed  by  the  posterior  waH  of  the  bladder  above  and 
the  anterior  wall  of  the  vagina  below.  In  the  early  development  of  a 
cystocele  the  walls  of  the  bladder  and  vagina,  which  constitute  the 
cystocele,  undergo  hypertrophy,  but  as  the  cystocele  enlarges,  these 
walls  become  stretched  and  blanched.  The  vaginal  walls  become  dry 
and  glistening.  In  extreme  cases  decubitus  ulcers  develop  upon  the 
vaginal  surface.  The  ureters,  as  they  pass  into  the  bladder,  may  become 
so  displaced  as  to  lead  to  constriction,  with  subsequent  dilatation; 
this,  however,  is  rare. 


Fig.  170 


Fig.   171 


Longitudinal  section  of  the  vagina.   Segment  showing 
posterior  wall.     (Testut.) 


Segment  showing  anterior  wall. 


Symptoms. — A  small  cystocele  presents  no  symptoms.  It  is  only 
when  the  relaxation  is  great  that  symptoms  arise.  The  symptoms 
common  to  cystocele  are  a  sense  of  fulness  at  the  vulvovaginal  orifice, 
a  feeling  of  heaviness  and  dragging  in  the  pelvis,  and  loss  of  power 
in  urinating. 

Sense  of  Fulness  at  the  Vulvovaginal  Orifice. — The  patient  expresses 
the  belief  that  her  "womb  comes  down"  when  she  stands,  and  par- 
ticularly when  she  exerts  herself  at  stool  or  in  lifting.  Here  the  increase 
19 


290  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

in  the  intra-abdominal  pressure  forces  the  pelvic  structures  downward 
and  exaggerates  the  cystocele. 

Feeling  of  Heaviness  and  Dragging  in  the  Pelvis. — This  feeling  is 
contributed  to  more  by  the  prolapsed  uterus  than  by  the  cystocele. 
Relief  comes  from  lying  down. 

Loss  of  Power  in  Urinating. — Residual  urine  accumulates  in  the 
vesical  pouch,  and  the  dislocated  bladder  is  placed  at  a  disadvantage 
in  emptying  itself  because  of  the  faulty  contractions  of  the  bladder 
and  the  inability  of  the  intra-abdominal  pressure  to  exert  a  direct 
influence  upon  the  bladder.     As  a  result  the  patient  is  compelled  to 

Fig.   172 


•%' 


Vulva  of  non-parous  woman  closed.     (Jewett.) 


make  undue  exertion  in  urinating,  and  believes  that  she  has  lost  the 
power  to  void  urine.  She  acquires  the  habit  of  making  pressure  with 
the  index  finger  upon  the  cystocele  as  an  aid  to  voiding.  Decomposition 
of  the  residual  urine  leads  to  irritability  of  the  base  of  the  bladder, 
and  this,  in  turn,  to  frequency  of  urination,  with  more  or  less  discomfort. 
Differential  Diagnosis.^Cystocele  is  to  be  differentiated  from  cysts 
and  fibroids  of  the  anterior  wall  of  the  vagina  and  from  hernia  of  the 
anterior  vaginal  wall.     A  sound  placed  in  the  bladder  and  the  index 


MALPOSITIONS  OF   THE  VAGINAL  WALL 


291 


finger  of  the  left  hand  placed  in  the  vagina  will  serve  to  differentiate  a 
cystocele  from  these  conditions. 

Prognosis. — Unless  corrected  by  operative  means  the  tendency  is 
toward  exaggeration  of  the  dislocation.  Without  operation  there  is  no 
cure.  The  operative  prognosis  is  at  best  uncertain.  If  the  patient  is 
young  and  the  muscular  development  is  good,  operation  will  usually 
effect  a  complete  cure  so  far  as  the  symptoms  are  concerned,  but  there 
will  commonly  be  found  some  degree  of  pouching  afterward.  When  the 
pelvic  supports  are  poorly  developed,  and  there  is  much  stretching  of 
the  parts,  it  is  difficult  to  obtain  a  perfect  result.  In  such  cases  the 
operator  must  be  satisfied  to  obtain  a  degree  of  improvement. 

Fig.   173 


Vulva  of  non-parous  woman  open,  hymen  intact.     (Jewett.) 


Treatment. — The  treatment  is  prophylactic,  palliative,  and  operative. 

Prophylactic  Treatment. — To  prevent  the  development  of  a  cystocele 
it  is  essential  that  the  general  nutrition  of  the  patient  should  be  kept 
at  a  normal  standard.  This  implies  due  regard  for  all  hygienic  prin- 
ciples.   The  diet  and  exercise  must  be  regulated  to  suit  the  individual 


292  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

case.  The  dress  should  be  so  arranged  that  all  undue  constriction  and 
traction  about  the  waist  line  is  eliminated.  The  bowels  should  be 
regulated  so  as  to  avoid  straining  at  stool,  and  such  duties  as  call  for 
great  exertion  should  be  avoided  so  far  as  possible.  These  precautionary 
measures  are  of  importance  following  childbirth,  in  order  that  the 
pelvic  tissues  ma}-  resume  their  normal  tone  and  position. 

Fig.  174 


"f- 


Vulva  of  parous  woman  closed.     (Jewett.) 

The  early  correction  of  injuries  to  the  pelvic  floor  is  imperative, 
inasmuch  as  the  starting-point  of  a  cystocele  is  usually  a  lacerated 
perineum.  The  speedy  and  complete  involution  of  the  uterus  following 
childbirth  is  necessary.  This  implies  the  prevention  of  infection,  direct- 
ing the  posture  of  the  patient  to  avoid  the  development  of  displace- 
ments, and,  when  there  is  great  relaxation  of  the  abdominal  walls,  the 
adjustment  of  a  properly  fitting  abdominal  support.  Finally,  the  cor- 
rection of  a  displacement  of  the  uterus  by  the  introduction  of  a  suitable 
pessary  or  by  operation  will  often  avert  the  development  of  a  cystocele. 


MALPOSITIONS  OF  THE  VAGINAL   WALL 


293 


Palliative  Treatment. — Not  every  cystoeele  should  be  operated  upon, 
and  not  every  operation  is  successful,  hence  the  necessity  of  palliative 
measures  for  the  relief  of  distressing  symptoms.  The  following  measures 
are  to  be  employed: 

Abdonmial  Support. — When  the  abdominal  wall  is  relaxed  and  pendu- 
lous a  suitable  abdominal  supporter  should  be  worn  to  reduce  the 
intra-abdominal  pressure.  Tight-lacing  and  clothing  that  constrict 
the  waist  should  be  avoided. 

Fig.  175 


Vulva  of  parous  woman  open.     (Jewett.) 

Vaginal  Tampons. — Vaginal  tampons  of  lambs'  wool  may  be  worn 
as  a  support  to  the  sagging  vaginal  walls.  These  should  be  removed 
when  fouled  by  the  secretions  in  the  vagina. 

Vaginal  Douches. — Astringent  vaginal  douches  of  hot  water,  with 
alum,  zinc,  or  tannin,  may  be  given  night  and  morning.  These  will 
keep  the  vagina  free  of  irritating  secretions,  and  will  also  have  a  puck- 
ering effect  upon  the  walls  of  the  vagina. 

Pessaries. — The  only  effective  pessary  for  the  support  of  a  cystoeele 
is  Skene's.  The  method  of  introduction  is  the  same  as  for  an  Albert- 
Smith  pessary.     (See  chapter  on  Pessaries.) 


294 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


Operative  Treatment. — Anterior  Colporrhaphy. — The  first  step 
in  the  development  of  a  prolapsed  uterus  is,  as  a  rule,  the  relaxation 
and  sagging  of  the  anterior  wall  of  the  vagina.     Too  frequently  this 


Fig.  176 


Topography  of  bladder  and  ureters  in  cystocele  as  shown  by  sagittal  section:  A.h.,  hypogastric 
artery;  A.i.e.,  external  iUac  artery;  C.d.,  Douglas'  pouch;  C.v.u.,  vesico-uterine  pouch;  Cy.,  cystocele; 
L.S.,  infundibulopelvic  ligament;  Po.,  portio  vaginaUs;  R.,  rectum;  T.,  Fallopian  tube;  U.,  ureter; 
Ua.,  urethra;  Um.,  ureteral  orifice;  Ut.,  uterus;  Ve.,  bladder.     (Tandler  and  Halban.) 


fact  is  not  appreciated,  and  hence  the  prolapsus  is  allowed  to  develop. 
The  sagging  of  the  anterior  wall  of  the  vagina  proceeds  from  a  point 
near  the  urethra  upward  to  or  near  the  cervical  attachment;  rarely 
does  the  sagging  proceed  from  above  downward. 


MALPOSITIONS  OF  THE  VAGINAL   WALL 


295 


Technic  of  Anterior  Colporrhaphy. — This  operation  was  introduced 
by  Marion  Sims.  Fricke,  Hegar,  Winckel,  Martin,  Emmet,  Kiistner, 
Fehling,  and  others  have  made  various  modifications  in  the  technic. 


Fig.  177 


Diamond-shaped  area  outlined.     Flap  of  vaginal  mucous  membrane  dissected  from  the  bladder. 

Step  one. 

Four  two-pronged  tenacula  are  required:  one  grasps  the  anterior 
lip  of  the  cervix  and  by  it  traction  is  made  downward;  a  second  grasps 
the  vaginal  wall  at  a  point  immediately  below  the  external  urethral 
orifice  and  with  it  gentle  traction  is  made  upward;  the  other  two  are 
placed  one  on  either  side  of  the  cystocele,  at  the  midpoint,  and  with 
them  gentle  traction  is  made  outward.  In  this  manner  the  cystocele  is 
so  stretched  as  to  form  a  diamond-shaped  area,  which  is  readily 
accessible  to  the  operator. 


296 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


The  area  of  denudation  is  then  outlined,  with  a  sharp  knife,  begnnung 
at  the  upper  angle  and  extending  on  either  side  to  the  outer  angles 
and  thence  to  the  lower  angle.  The  incision  should  not  extend  deeper 
than  the  vaginal  mucosa.  It  will  facilitate  the  process  of  denudation 
to  make  a  straight  incision  joining  the  upper  and  lower  angles,  thereby 
bisecting  the  flaps  to  be  denuded. 


Row  of  buried  plain  catgut  placed  in  bladder  wall  for  the  purpose  of  invaginating  the  bladder. 

Second  step. 

With  scalpel  and  tissue  forceps  the  mucous  membrane  is  denuded 
as  shown  in  Fig.  177,  and  exposes  a  raw  surface  as  shown  m  l^ig.  178. 

The  next  step  is  to  unite  the  lateral  margins  of  the  denuded  area, 
crowding  the  bladder  backward,  thereby  disposing  of  the  cystocele. 
To  do  this  a  No.  2  ten-day  chromic  catgut  suture  is  passed  m  an  over- 


MALPOSITIONS  OF  THE  VAGINAL  WALL 


29- 


and-over  lock  stitch  from  the  upper  to  the  lower  angle,  or  interrupted 
sutures  are  passed  as  shown  in  Fig.  180. 

When  an  extensive  area  is  denuded,  additional  buried  stitches 
may  be  required  to  approximate  the  deeper  structures.  This  is  done 
by  making  a  running  stitch  in  one  or  more  layers  with  No.  2  plain 
catgut,  and  over  this  the  vaginal  mucosa  is  approximated  with  ten -day 
chromic  catgut.  Care  must  be  taken  to  avoid  injury  to  the  bladder 
and  ureters  and  to  leave  no  dead  spaces. 


Fig.   179 


Fig.  180 


Running  suture  of  chronic  catgut  approximating  the 
free  margins  of  the  vaginal  wall.     Third  step. 


Operation  complete.     Fourth  step. 


Noble's  Operation. — Charles  P.  Noble^  has  devised  an  admirable 
operation  for  the  correction  of  cystocele.  After  curetting  the  uterus 
and  amputating  the  cervix  when  necessary,  traction  is  made  downward 
upon  the  cervix  by  means  of  a  vulsellum  forceps.  Counter-traction  is 
made  upward  upon  the  anterior  wall  of  the  vagina  by  means  of  a  bullet 
forceps  inserted  immediately  below  the  external  orifice  of  the  urethra. 
In  this  manner  the  anterior  wall  of  the  vagina  is  put  upon  the  stretch. 
A  narrow  strip  of  vaginal  wall  is  excised  between  these  two  forceps. 
Artery  forceps  are  made  to  grasp  the  sides  of  the  vaginal  opening,  and 
outward  traction  is  made  upon  them  while  the  bladder  is  stripped 
from  the  cervix  upward  to  the  peritoneal  reflexion  and  laterally  from 
the  vaginal  walls  to  an  extent  that  will  permit  of  the  ascent  of  the 
prolapsed  bladder  into  the  peritoneal  cavity.  The  redundant  vaginal 
tissue  is  next  excised,  taking  care  that  too  much  tissue  is  not  removed, 

1  Jour.  Amer.  Med.  Assoc,  December  14,  1907. 


298 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


The  area  excised  is  usually  oval,  with  the  base  toward  the  cervix.  Two 
rows  of  continuous  sutures  are  now  placed.  At  the  upper  extremity 
the  sutures  embrace  the  deeper  layers  of  the  vagina  and  base  of  the 
bladder,  and  below  this  point  the  deeper  layers  of  the  vagina  are  sutured 
to  the  anterior  wall  of  the  cervix.    This  line  of  sutures  is  followed  bv 


Fio.   181 


■^ — Absc. 


Retroflexion  of  uterus,  with  partial  prolapse  of  uterus  and  elongation  of  cervix, 
uterus.      (Tandler  and  Halban.)  . 


Abscess  in  wall  of 


a  second  continuous  suture,  which  approximates  the  free  margins  of 
the  vaginal  wall.  When  there  is  much  tension  on  the  continuous-  sutures 
it  is  advisable  to  pass  two  or  more  interrupted  sutures  of  chromicized 
catgut  through  vaginal  walls  and  cervix. 

Amputation  of  the  Cervix. — When  the  cervix  is  elongated  or 
badly  lacerated  it  should  be  amputated  as  the  next  step,  following 
anterior  colporrhaphy.    For  the  technic  of  the  operation  see  page  294. 


MALPOSITIONS  OF  THE  VAGIXAL   WALL 


299 


After  Treatment. — See  Perineorrhaphy. 

Rectocele.— Synonyms.— Prolapse  of  the  posterior  wall  of  the  vagina; 
rectovaginal  hernia. 

Etiology.— 1.  Relaxation  of  the  vaginal  walls  and  pelvic  floor  following 
labor. 

2.  Lacerations  of  the  vaginal  walls  and  pelvic  floor  following  labor. 

3.  Prolapsus  uteri. 

4.  General  malnutrition,  with  loss  of  muscular  tone. 

5.  Violent  muscular  exertion. 

Fig.  182 


Anterior  wall  of  the  rectum  bulges  into  the  vagina  (rectocele).  M.,  rectum;  S.,  vagina;  BL,  bladder; 
E.V.U.,  vesico-uterine  pouch;  E.r.u.,  cul-de-sac  of  Douglas;  S.r.v.,  rectovaginal  septum;  A.u.,  uterine 
artery;  Ur.,  ureter. 

Anatomy.— The  pelvic  floor  is  an  essential  factor  in  the  support  of 
the  pelvic  organs,  and  when  overstretched  or  torn,  there  is  a  tendency 
on  the  part  of  the  uterus,  bladder,  rectum,  and  vaginal  walls  to  pro- 
lapse. It  is  in  this  manner  that  the  majority  of  rectoceles  arise,  'While 
it  is  possible  for  the  posterior  waH  of  the  vagina  to  prolapse  without 


300 


MALPOSITIOXS  OF  THE  GEXITAL  ORGAXS 


carrying  with  it  the  anterior  wall  of  the  rectum,  it  may  be  said  that  it 
is  exceptional,  the  rule  being  that  the  anterior  wall  of  the  rectum  is 
carried  forward  with  the  posterior  wall  of  the  vagina. 

In  the  early  development  of  a  rectocele  the  vaginal  wall  is  thickened 
and  tlirown  into  folds,  but  with  increase  in  size  of  the  rectocele  the 
vaginal  wall  looses  its  folds  and  becomes  thin  and  glistening.  These 
changes  are  particularly  marked  in  women  of  advanced  age.  TMien 
the  pouching  walls  have  protruded  from  the  vulva  the  mucosa  becomes 
leathery  and  ulcers  may  develop;  the  rectal  mucosa  may  become 
inflamed  and   ulcerated,  and   hemorrhoids,  fissures,  and  fistula  may 


arise 


Fig.  183 


E.T-U. 


Almost  complete  prolapse  of  the  anterior  vaginal  walls  and  posterior  vaginal  wall  Elongation 
of  the  cer\-ix.  Partial  prolapse  of  the  uterus.  Anteflexio-versio-uteri.  Cystocele.  Hernia  of  the 
cul-de-sac.    R,  rectum;  E.r.u.,  cul-de-sac;  A,  hernia.     (Tandler  and  Halban.) 


Symptoms. — Xo  symptoms  arise  from  a  small  rectocele. 
developed  the  following  symptoms  are  complained  of: 

1.  Feeling  of  fulness  at  the  vulvovaginal  orifice. 

2.  Feeling  of  heaviness  and  dragging  in  the  pelvis. 

3.  Loss  of  power  in  defecation. 


When  well- 


MALPOSITIONS  OF  THE  VAGINAL  WALL 


301 


Feeliiig  of  Fulness  at  the  Vulvovaginal  Orifice. — The  patient  will 
usually  say  that  her  "womb  comes  down"  when  she  stands  or  when 
at  stool;  the  feeling  of  fulness  at  the  vulvovaginal  orifice  is  due  to  the 
bulging  rectocele  and  accompanying  cystocele. 

Feeling  of  Heaviness  and  Dragging  in  the  Pelvis. — The  feeling  of 
heaviness  and  dragging  in  the  pelvis  is  due  to  the  prolapse  of  the  pelvic 
organs  associated  with  the  rectocele. 


Fig.  184 


Rectocele.     The  index  finger  in  the  rectum  finds  its  way  into  the  rectal  pouch  which  protrudes 

into  the  vagina. 


Loss  of  Power  in  Defecation. — Under  normal  conditioEs  in  the  act 
of  defecation  the  perineum  is  elevated,  the  vaginal  canal  is  closed, 
the  contraction  of  the  levator  ani  assists  the  sphincter  in  dilating, 
and  the  deep  pelvic  fascia  further  supports  the  leetum.  It  will 
be  seen  that  the  anterior  wall  of  the  rectum,  under  normal  condi- 
tions, is  well  supported,  but  with  the  pelvic  floor  stretched  or 
torn  these  supports  are  weakened,  and,  as  a  result,  an  undue  strain 
is  placed  upon  the  anterior  wall  of  the  rectum  and  posterior  wall  of 
the  vagina;  this  gives  rise  to  a  rectocele,  and  once  started  it  tends  to 
increase  in  size.  Constipation  is  thereby  engendered,  and  there  is  a 
feeling  on  the  part  of  the  patient  that  she  is  unable  to  thoroughly 
evacuate  the  rectum. 

Diagnosis. — With  the  patient  in  the  lithotomy  position  and  the 
vulva  exposed  she  is  asked  to  strain.  The  rectocele  will  then  appear 
at  the  vulvar  outlet  as  a  globular  mass,  which  is  readily  reduced  by 
pressure  with  the  finger.  The  index  finger  inserted  into  the  rectum 
will  identify  beyond  question  the  rectocele. 


302  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

Treatment. — The  only  way  to  correcting  a  rectocele  is  by  means  of  a 
a  plastic  operation.  Without  operation  the  tendency  is  to  increase 
in  size. 

Prophylaxis. — See  Prophylaxis  under  Vesicocele,  page  291. 

Palliative  Treatment. — When  operative  interference  is  impossible  and 
the  symptoms  are  distressing,  some  degree  of  relief  may  be  obtained 
by  the  following  procedures: 

Lessening  of  the  Intra-abdominal  Pressure. — This  can  be  accomplished 
by  removing  all  traction  and  constriction  of  the  waist  through  faulty 
clothing,  by  relieving  constipation  to  obviate  straining  at  stool,  and 
finally  by  adjusting  a  suitable  abdominal  support  when  the  abdomen 
is  pendulous. 

Vaginal  Douches. — Vaginal  douches  of  hot  sterile  water  and  alum, 
zinc,  or  tannin  will  tend  to  shrink  the  tissues. 

Tampo7is. — Tampons  of  lambs'  wool  will  serve  as  a  temporary 
support. 

Pessaries. — Pessaries  are  not  always  successful.  A  large  cystocele 
and  rectocele,  with  a  gaping  vulvar  outlet,  will  not  permit  of  the  wear- 
ing of  any  sort  of  pessary  unless  it  be  a  cup  and  stem  pessary  attached 
to  an  abdominal  band. 

Less  pronounced  relaxation  of  the  pelvic  floor  and  vaginal  walls  may 
permit  the  wearing  of  a  ring  pessary. 

Operative  Treatment. — See  Perineorrhaph}'. 

Vaginal  Hernia. — Etiology. — Vaginal  hernias  are  thought  by  some 
to  be  due  to  a  congenital  maldevelopment  of  the  pelvic  peritoneujn 
and  pelvic  organs. 

So  far  as  the  author's  knowledge  goes  the  lesion  is  acquired  through 
labor,  in  which  the  pelvic  floor  is  stretched  and  torn. 

As  compared  with  rectocele  and  cystocele,  vaginal  hernia  is  a 
rare  condition.  The  more  common  of  the  two  is  posterior  vaginal 
hernia. 

Anatomy. — One  or  more  loops  of  small  bowel  find  their  way  either 
in  front  or  behind  the  broad  ligaments;  the  former  to  produce  an 
anterior  vaginal  hernia,  the  latter  a  posterior  vaginal  hernia. 

An  anterior  vaginal  hernia  starts  in  the  vesico-uterine  pouch  of 
peritoneum;  this  peritoneal  fold  is  forced  downward  between  the 
bladder  and  vagina,  and  may  enter  the  labium  majus  in  its  posterior 
third. 

A  posterior  vaginal  hernia  starts  in  the  cul-de-sac  and  descends 
between  the  rectum  and  vagina,  separates  the  muscular  fibers  of  the 
levator  ani,  and  finally  appears  in  the  perineal  body  or  in  the  posterior 
segment  of  the  labium  majus. 

Symptoms. — The  clinical  manifestations  of  vaginal  hernia  Ao  not 
differ  from  those  found  in  a  cystocele  or  rectocele,  there  being  a  sense 
of  fulness  in  the  vagina,  vulva,  or  perineum  and  a  feeling  of  weight 
and  dragging  in  the  pelvis.  There  should  be  no  disturbance  of  urination 
or  defecation. 


MALPOSITIONS  OF  THE  VAGINAL  WALL 


303 


Diagnosis. — Care  must  be  taken  not  to  mistake  a  vaginal  hernia  for 
a  cystocele,  rectocele,  tumor  of  the  vagina,  Bartholinean  cyst,  or 
inguinal  hernia  that  has  descended  into  the  labium  majus. 


Fig.   ISo 


Partial  prolapse  of  the  uterus.     Moderate  elongation  of  the  cervix.     Hernia  of  the  cul-de-sac  of 
Douglas.     Beginning  cystocele. 

A  vaginal  hernia  is  distinguished  from  these  lesions  by  its  soft  con- 
sistency, by  becoming  tense  on  coughing,  by  being  reduced  on  pressure, 
and  by  causing  a  gurgling  sound  on  reduction.  Finally,  by  inserting 
a  finger  within  the  rectum  and  another  within  the  vagina  the  presence 
of  an  intervening  body  between  the  vaginal  wall  and  .rectal  wall  is 
disclosed.  A  sound  placed  in  the  bladder  and  the  index  finger  in  the 
vagina  will  reveal  a  similar  condition  in  the  presence  of  an  anterior 
vaginal  hernia. 


304 


MALPOSITIONS  OF  THE  GEXITAL  ORGANS 


All  Bartholinean  cysts  and  vaginal  tumors  are  readily  distinguished 
from  vaginal  hernias  by  not  disappearing  on  pressure  and  by  their 
sharply  circumscribed  character. 

An  inguinal  hernia  when  reduced  will  follow  the  course  of  the  inguinal 
canal  and  is  in  this  way  distinguished  from  a  vaginal  hernia. 

Treatment. — 1.  Evacuate  the  bladder  and  rectum. 

2.  Place  the  patient  in  the  knee-elbow  position. 

3.  Reduce  the  hernia  by  gentle  manipulations. 

4.  Prevent  recurrence  by  introducing  a  hard-rubber  ring  pessary. 

5.  Radical  cure:  The  only  satisfactory  manner  of  dealing  with  this 
condition  is  by  operation.  Pessaries  will,  at  best,  afford  only  temporary 
relief. 

Fig.  186 


Rectovaginal  hernia.     Pouch  of  peritoneum  is  caught  with  a  forceps  and  twisted  into  a  rope. 
First  step.     (After  Ashton.) 

Posterior  Vagixal  Herxla. — Posterior  vaginal  hernia  is  operated 
in  the  following  steps: 

1.  Abdominal  incision  and  correction  of  any  existing  uterine  dis- 
placement. 

2.  After  separating  any  existing  adhesions  the  cul-de-sac  is  seized 
with  forceps  and  twisted  upon  itself  to  form  a  tight  cord.  The  cord 
is  then  transfixed  at  its  base  by  a  ligature  of  linen,  which  is  tied  and 
the  cord  severed  above  the  ligature.  This  obliterates  the  hernial  sac. 
If  the  sac  cannot  be  pulled  out  of  its  advanced  position  the  space 
should  be  obliterated  to  the  normal  level  of  the  cul-de-sac  by  in- 
terrupted catgut  sutures. 


MALPOSITIONS  OF  THE  UTERUS 


305 


3.  Plastic  operations  are  performed  upon  the  anterior  and  posterior 
vaginal  walls  and  perineum  when  indicated. 

Anterior  Vaginal  Hernia.— The  operative  steps  do  not  differ 
essentially  from  those  taken  in  posterior  vaginal  hernia. 


Fig.  187 


'•}f??^^'i- 


Retrovaginal  hernia.    A  rope  of  peritoneum  is  ligated  at  its  base  with  linen  and  severed  above  the 
ligature.     Second  step.     (After  Ashton.) 


MALPOSITIONS  OF  THE  UTERUS 


Normal  Position. — Under  perfectly  physiological  conditions  the 
uterus  may  occupy  widely  varying  positions.  In  order  that  these 
physiological  changes  in  position  may  occur,  the  uterine  ligaments, 
pelvic  peritoneum,  and  cellular  tissue  must  possess  their  normal  degree 
of  elasticity  (Fig.  192). 

The  normal  position  of  the  uterus  varies  with  the  attitude  of  the 
individual.  It  is  crowded  backward  by  a  full  bladder,  forward  by  a 
loaded  rectum,  and  forward  and  downward  by  increase  in  the  intra- 
abdominal pressure  from  coughing,  straining  at  stool,  etc. 

By  reference  to  Figs.  194  and  195,  it  will  be  seen  that  the  normal 

position  of  the  uterus  of  a  virgin  in  the  erect  posture,  with  the  bladder 

and  rectum  empty,  is  one  of  anteversion,  slight  anteflexion,  anteposi- 

tion,  and  slight  lateral  position.    The  body  of  the  uterus  lies  about  1  cm. 

20 


306 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


behind  the  upper  border  of  the  symphysis  pubis,  the  cervix  points  to 
the  second  sacral  vertebra,  and  Hes  about  2  cm.  in  front  of  the  sacro- 


FiG.  188 


Fig.  189 


Fig.   190 


Fig.  191 


Figs.  188  to  191.— Uterus  at  varying  periods  of  life.  Fig.  188,  uterus  of  newborn  child;  Fig.  189, 
uterus  at  puberty;  Fig.  190,  nuUiparous  uterus  fuUy  developed;  Fig.  191,  multipafous  uterus. 
(Modified  from  Chrobak   and   Rosthorn.) 

coccygeal  articulation.  In  the  virgin  there  is  less  anteflexion  than  in 
a  multipara.  The  explanation  lies  in  the  fact  that  the  small  resisting 
vagina  presses  the  slender  cervix  backward  (Figs.  193  and  194). 


TUBAL    VESSELS 


PLATE    XVI 


Fig.   1 


ANASTOMOSIS  OF 

UTERINE     AND 
OVARIAN    ARTERIES 
HELICINE    BRANCHES  '\ 


FALLOPIAN 
TUBE 


^^/^ 


UTERINE 
VEINS 


VAGINAL   VENOU 


UTERINE    ARTERY 


\  ill      SUPERIOR    VAGINAL 

ARTERIES 


OS    UTERI        VAGINA    CUT    OPEN    BEHIND 

Bloodvessels  of  the  Uterus  and  Its  Appendages.      (Testut.) 


Fig.   2 


UTEHO-OVARIAN 

^       LIGAMENT 


UTERO-OVARIAN 
VESSELS 


UTERINE    VESSELS 


ao 


y^ 


DORSAL    FOLD    OF 
BROAD    LIGAMENT 


OS    UTERI  VAGINA 

The  Uterus  and  Adnexa  Viewed  from  in  Front.      (Testut.) 


MALPOSITIONS  OF  THE   UTERUS 

Fig.  192 


307 


Internal  iliac 

artery. 
External  iliac 

arterj'. 
Vesicovaginal 

artery. 


The  uterosacralligaments  or  folds  of  Douglas.      (Testut.) 


Fig.  193 


6  Is 


9    11 


Coronal  section  of  the  uterus  of  a  nulliparous  Coronal  section  of  the  uterus  of  a  multiparous 

woman.  woman. 

1,  fundus;  2,  lateral  walls  of  the  body;  3,  cervix;  4,  isthmus;  5,  cavity  of  the  body;  o  ,  internal  wall 
of  the  body;  6,  cornu;  6',  opening  of  the  Fallopian  tube;  7,  arbor  vitse;  8,  os  internum;  9,  os  externum; 
10,  10  ,  lateral  fornices;  11,  posterior  vaginal  wall.     (Testut.) 


308 


MALPOSITIOXS  OF   THE  GEXITAL   ORGAXS 


Pathological  changes  in  the  position  of  the  uterus  and  its  neighboring 
organs  are  more  or  less  permanent.  There  is  no  tendency  toward  a 
spontaneous  return  to  the  normal  position. 


Fig.  195 


Normal  position  of  the  uterus.     The  uterus  lies  anteposed,  anteverted,  and  slightly  anteflexed  when 
the  bladder  and  rectum  are  empty  and  the  patient  in  the  upright  position. 


Pathological  Mobility. — The  uterus  becomes  abnormally  movable 
when  the  normal  supports  are  weakened  or  have  given  way.  A  relax- 
ation of  the  uterine  ligaments,  of  the  pelvic  floor  and  of  the  abdominal 
muscles  will  lead  to  abnormal  mobihty  of  the  uterus.  Under  such 
conditions  the  uterus  gravitates  according  to  the  position  of  the  patient. 
In  the  upright  posture,  with  the  bladder  empty,  it  may  fall  forward 
and  downward.  In  the  dorsal  posture  with  the  rectum  empty,  the 
uterus  falls  backward  into  the  hollow  of  the  sacrum.  This  condition, 
when  uncomplicated,  cannot  be  regarded  seriously  from  a  clinical  point 
of  view. 

Pathological  Fixation. — An  abnormally  movable  uterus  may  lodge 
in  a  position  where  it  becomes  fixed  and  immovable.  It  is  thereby 
evident  that  the  factors  causing  increased  mobility  of  the  organ  may 
lead  to  a  more  or  less  permanent  fixation.  Fixation  of  a  misplaced 
uterus  will  be  considered  in  subsequent  chapters.  We  will  here  discuss 
only  fixation  of  the  normally  placed  uterus.    By  this  is  meant  a  uterus 


PLATE    XV 


Bloodvessels  of  the  Abdomen  and  Pelvis.       (Leipniann.) 


1.  Aorta. 

2.  Ovarian  artery. 

3.  Inferior  mesenteric  artery. 

4.  Common  iliac  artery. 

5.  External  iliac  artery. 

6.  Internal  iliac  artery. 

7.  Inferior  gluteal  artery. 

8.  Common  pudendal  artery. 

9.  Obturator  artery. 

10.  Uterine  artery. 

1 1 .  Superior  vesical  artery. 

12.  Inferior  epigastric  artery. 

A.  Pudendal  plexus. 

B.  Vesicovaginal  plexus. 


C.  Inferior  uterine  vein. 

D.  Superior  uterine  vein. 

E.  Obturator  vein. 

F.  Internal  iliac  vein. 

G.  iSIedian  iliac  vein  (hemorrhoidal  plexus). 
H.  Hypogastric  vein. 

/.  External  iliac  vein. 
K.  Common  iliac  vein. 
L.  Vena  cava. 
M.  Ovarian  vein. 
iV.  Renal  vein. 

A.  Bulbus  vestibuli. 

B.  Corpus  clitoris. 

C.  Crus  clitoris. 


MALPOSITIONS  OF  THE  UTERUS 


309 


in  normal  position,  but  lacking  the  degree  of  elasticity  and  mobility 
that  is  found  in  health. 

Parametritis  atrophicans  (Freund),  or  parametritis  posterior 
(Schultze),  is  a  condition  frequently  overlooked.  The  uterosacral 
ligaments  are  firmly  contracted  and  tender.  By  thickening  and  con- 
traction of  the  uterosacral  ligaments  the  cervix  is  drawn  backward 
and  the  whole  uterus  restricted  in  its  movements.  A  chronic  metritis 
will  diminish  the  normal  flexibility  of  the  uterus,  as  may  also  carcinoma 
and  fibroids.    Chronic  cervical  catarrh  may  stiffen  the  cervix. 

Fig.  196 


Anteposition.  The  loaded  rectum  crowds  the  uterus  forward  into  anteposition  when  the  bladder 
is  empty.  The  cul-de-sac  of  Douglas  is  almost  obliterated.  When  the  rectum  is  empty  the  uterus 
will  fall  back  into  the  normal  position. 


Anteposition. — Anteposition  is  an  exaggerated  normal  position;  the 
uterus  lies  immediately  behind  the  abdominal  wall  and  symphysis 
pubis.  Among  the  causes  of  anteposition  of  the  uterus  are  swellings 
behind  crowding  the  uterus  forward,  or  adhesions  attached  to  the 
anterior  surface  of  the  uterus  pulling  it  forward,  such  as  are  made 
by  ventrofixation.  The  latter  condition  is  very  unusual.  The  most 
common  causes  are  tubal  and  ovarian  swellings  lying  in  the  cul-de-sac 
of  Douglas,  retro-uterine  hematocele,  tumors  of  the  uterus  bulging 
from  the  posterior  surface   of   the   uterus,   and   newgrowths   of  the 


310  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

rectum.  Anteposition  is  often  combined  with  elevation,  anteversion, 
and  anteflexion. 

The  diagnosis  is  seldom  difficult.  On  bimanual  examination  the 
uterus  is  found  lying  close  to  the  anterior  abdominal  wall.  When 
caused  by  retro-uterine  swellings,  which  cannot  be  outlined  apart  from 
the  uterus,  the  sound  will  be  required  to  locate  the  position  of  the  organ. 
A  retro-uterine  tumor,  crowding  the  uterus,  forward,  is  recognized 
by  its  irregular  outline  and  its  consistency.  Here,  again,  the  uterine 
sound  will  be  of  service  in  locating  the  uterus.  In  ever}^  doubtful 
case  an  anesthetic  should  be  administered.  The  one  symptom,  com- 
monly present,  is  frequent  urination.  (See  Plate  XVIII  and  Fig.  196.) 
Anteposition  of  the  uterus  is  but  an  exaggerated  normal  position,  and 
is  not  to  be  regarded  seriously.  The  determining  factors  and  associated 
lesions,  as  above  named,  alone  demand  serious  consideration. 

Retroposition. — In  retroposition  the  uterus  lies  back  of  the  normal 
position  without  change  in  the  direction  of  its  long  axis.  The  causes 
of  retroposition  are  swellings  in  front  of  the  uterus  or  adhesions  behind 
it.  Among  swellings  in  front  of  the  uterus  are  uterine  fibroids,  tumors 
of  the  bladder  and  anterior  abdominal  wall,  persistent  distention  of  the 
bladder,  and,  occasionally,  enlarged  tubes  and  ovaries.  Adhesions 
behind  the  uterus  causing  retroposition  are  largely  confined  to  the 
peritoneal  cavity,  and  involve,  more  or  less  of  the  posterior  surface  of 
the  uterus.  These  adhesions  most  frequently  result  from  extension 
of  an  inflammation  from  the  tubes  which,  when  inflamed,  commonly 
lie  behind  the  uterus.  In  abnormal  mobility  of  the  uterus,  due  to  a 
relaxation  of  the  normal  supports,  the  uterus  falls  into  retroposition 
when  the  patient  lies  upon  her  back. 

It  is  important  to  recognize  the  cause  of  the  displacement,  inasmuch 
as  retroposition  per  se  is  of  little  clinical  significance.  When  no  tumor 
mass  or  adhesions  are  found  in  the  pelvis  and  the  retroposed  uterus 
displays  an  abnormal  mobility,  the  displacement  is  regarded  as  due 
to  relaxation  of  the  uterine  supports. 

It  is  not  always  possible  to  diagnosticate  the  presence  of  adhesions, 
even  when  the  examination  is  made  under  anesthesia.  Experienced 
operators  will  testify  to  the  frequency  with  which  perimetritic  adhesions 
are  unexpectedly  found  after  opening  the  abdominal  cavity.  This  fact 
alone  would  seem  to  render  the  Alexander  operation  of  shortening  the 
round  ligaments  through  the  inguinal  canal  an  uncertain  procedure. 

Perimetritic  adhesions  are  confined  to  surfaces  normally  covered 
with  peritoneum.  They  are  found  with  the  greatest  frequency  about 
inflamed  tubes  and  ovaries,  and  are  therefore  most  commonly  located 
beside  or  behind  the  uterus.  The  uterus  is  rarely  absolutely  fixed. 
The  degree  of  mobility  depends  upon  the  location  of  the  adhesions, 
their  extent,  length,  and  firmness.  Adhesions  binding  the  uterus  to 
movable  structures,  such  as  bowel  and  omentum,  usually  permit  more 
or  less  mobility  on  the  part  of  the  uterus.  The  diagnosis  of  a  perimetritic 
exudate — that  is,  of  an  exudate  lying  within  the  peritoneal  cavity  and 
binding  together  the  peritoneal  surface  of  the  uterus  with  the  peritoneal 


PLATE    XVIII 


Fig.    1 


Anteposition  of  the  uterus.  A  retrouterine  hsematoeele  fills  the 
eul-de-sae  of  Douglas  and  the  space  between  the  uterus  and  sacrum. 
The  uterus  is  crowded  forward. 


Fig.    2 


Retrouterine   Haematorna   Crowding  the   Cul-de-sac  of 

Douglas  Up  and  the  Uterus  Upward 

and  For^A^ard. 


MALPOSITIONS  OF  THE   UTERUS 


311 


surfaces  of  adjacent  structures,  from  an  exudate  involving  the  pelvic 
cellular  tissue — is  made  first  of  all  by  the  location.     A  parametritic 


Fig.  197 


Left  laterodisplacement  of  the  uterus.     The  left  broad  ligament  is  thickened  and  contracted  and 

drawn  the  uterus  to  the  left. 

Fig.  198 


Left  lateroversion  of  the  uterus.  The  uterus  is  crowded  to  the  left  side  of  the  pelvis,  the  long  axis 
of  the  uterus  inclines  to  the  left.  The  cause  of  the  displacement  is  a  broad  Ugament  cyst  of  the  right 
side  adherent  to  the  wall  of  the  pelvis. 


exudate  lies  low  in  the  pelvis  in  close  proximity  to  the  vaginal  wall, 
while  a  perimetritic  exudate  lies  on  a  higher  plane  and  is  more  difficult 
to  palpate  through  the  vagina.     Furthermore,   in  parametritis  the 


312 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


adhesive  bands  are  firmer  and  larger  than  in  perimetritis.  The  uterine 
sound  may  be  of  service  in  locating  the  position  of  the  uterus  apart 
from  inflammatory  exudates  and  new  formations. 

Lateroposition. — Lateroposition  of  the  uterus  is  generally  combined 
with  retroposition,  less  often  with  anteposition  and  descensus.  A 
limited  lateral  displacement  of  the  uterus  may  be  regarded  as  normal, 
and  is  explained  by  a  shortening  of  the  broad  ligament  on  the  side  to 
which  the  uterus  leans.  This  congenital  unilateral  shortening  of  the 
broad  ligament  and  also  of  the  uterosacral  ligament  accounts  for  the 
lateral  displacement  of  the  uterus,  not  infrequently  found  in  virgins. 

Fro.   199 


Retroposition  of  the  uterus.     The  uterus  is  drawn  backward  into  retroposition  by  peritoneal  bands 
ai  adhesions  extending  from  the  supravaginal  portion  of  the  cervix  to  the  sacrum. 


The  usual  causes  of  lateral  displacements  of  the  uterus  are  inflam- 
matory exudates  and  new-formations;  more  rarely  cicatricial  contrac- 
tions of  the  vaginal  wall  following  lacerations  and  sloughs.  Exudates  at 
the  sides  of  the  uterus,  when  large,  will  crowd  the  organ  to  the  opposite 
side  of  the  pelvis.  Later,  as  the  exudate  organizes  and  contracts,  the 
uterus  is  drawn  to  the  side  occupied  by  the  exudate  (Fig.  199).  If  the 
exudate  exerts  its  influence  along  the  entire  side  of  the  uterus,  the 
uterus,  as  a  whole,  will  be  first  pushed  to  the  opposite  side  and  later 
drawn  to  the  same  side.  If  the  exudate  involves  the  lower  segment 
of  the  broad  ligament,  leaving  the  body  of  the  uterus  free  and  movable, 


MALPOSITIONS  OF  THE   UTERUS 


313 


the  cervix  will  be  drawn  toward  the  side  in  which  the  exudate  has 
collected  and  the  body  of  the  uterus  is  tilted  to  the  opposite  side — a 
lateroversion  or  lateroflexion.  Likewise,  in  case  of  tumor  formations 
lying  beside  the  uterus,  if  the  force  is  distributed  along  the  side  of  the 
uterus  there  will  be  a  simple  lateroposition;  if  pressure  is  exerted  upon 
the  fundus  alone,  there  will  be  a  lateroversion  or  flexion  in  which  the 
body  will  be  crowded  to  the  opposite  side,  the  cervix  pointing  to  the 
side  occupied  by  the  tumor  (Fig.  198). 

Fig.   2C0 


Elevatio  uteri  following  a  ventrosuspension  of  the  uterus.     Adhesions  unite  the  fundus  of  the  uterus 
to  the  abdominal  wall  and  retain  the  uterus"  in  an  elevated  position. 


Slight  lateral  displacements  of  the  uterus  are  commonly  overlooked. 
When  found  they  should  always  lead  to  a  careful  bimanual  examination, 
and,  if  necessary,  these  examinations  should  be  under  anesthesia,  in 
view  of  determining  the  cause  of  the  lateral  position.  Reference  to 
Figs.  197  and  198  will  suggest,  in  a  general  way,  the  mechanism  of  the 
displacement.  The  displacement  is  due  to  traction  on  the  one  side  or 
to  crowding  on  the  other. 

Elevatio  Uteri. — In  elevatio  uteri  the  uterus  is  raised  above  the 
normal  plane  and  approaches  the  anterior  abdominal  wall.  In  uncom- 
plicated elevatio  uteri  the  long  axis  of  the  uterus  is  straightened.  It 
is  unusual  to  find  an  uncomplicated  elevation  of  the  uterus,  such  a 
condition  being,  as  a  rule,  associated  with  lateral,  anterior,  or  posterior 
displacements.      The   position    is   physiological    in   pregnancy.      The 


314 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


extent  to  which  the  uterus  may  be  drawn  upward  is  astonishing;  a 
perfectly  normal  uterus  may  be  raised  to  the  level  of  the  umbilicus. 

Causes  of  elevation  of  the  uterus  may  be  classified  under  two  general 
heads,  namely,  swellings  below  the  uterus  crowding  it  upward,  or  tumors 
and  adhesions  making  upward  traction  upon  the  uterus. 

Swellings  beneath  the  uterus  and  crowding  the  uterus  upward  are 
tumors  of  the  cervix,  vaginia,  and  rectum,  hematocele,  and  hematocolpos. 
Adhesions  binding  the  fundus  to  the  abdominal  wall  may  develop 
during  pregnancy  and  the  puerperium,  leaving  the  uterus  in  elevation 
after  the  puerperium.  Plate  XVIIL,  Fig.  2,  represents  the  uterus 
suspended  from  the  abdominal  wall  in  an  elevated  position.  A  Cesarean 
section  had  been  performed,  and  adhesions  developed  subsequently 
between  the  scar  in  the  abdominal  wall  and  that  of  the  uterus. 


Torsion  of  the  uterus  caused  by  twisting  of  the  pedicle  of  an  ovarian  cyst. 


A  subperitoneal  fibroid  attached  to  the  fundus  and  growing  into 
the  abdominal  cavity  may  elevate  the  uterus.  Either  the  pedicle 
must  elongate  or  the  uterus  will  be  drawn  upward,  since  the  tumor, 
when  it  can  no  longer  be  accommodated  in  the  pelvis,  rises  into  the 


MALPOSITIONS  OF  THE  UTERUS  315 

the  abdominal  cavity.  Tumors  of  ovary  with  short  pedicles  may 
operate  similarly. 

The  vagina  will  be  found  greatly  elongated  and  the  cervix  may  not 
be  within  reach  of  the  examining  finger. 

Torsion. — In  torsion  of  the  uterus  the  organ  is  twisted  upon  its 
long  axis.  This  displacement  rarely  exists  singly,  but  is  generally 
associated  with  anteposition,  lateral  position,  or  elevation.  Within 
perfectly  normal  limits  the  uterus  is  slightly  turned  upon  its  long  axis, 
through  shortening  of  the  broad  ligament  which  runs  outward  and 
slightly  backward. 

Causes  of  torsion  may  be  traction  on  the  one  hand  or  pressure  on 
the  other.  Adhesions  running  from  the  side  of  the  uterus  backward 
or  forward  may  turn  the  uterus  upon  its  long  axis,  as  will  also  pressure 
made  upon  the  side  of  the  uterus  by  tumor  formations. 

Fig.  201  represents  a  pedunculated  ovarian  tumor  lying  in  the 
abdominal  cavity.  The  tumor  has  been  turned  upon  its  long  axis, 
and  with  it  the  uterus  has  become  twisted.  It  is  even  possible  for  the 
uterus  to  be  severed  by  the  twisting.  The  blood  supply  to  the  uterus 
may  be  shut  off  completely  and  cause  gangrene,  or  partially  and  result 
in  atrophy.  Menstrual  and  intermenstrual  secretions  may  be  pent  up 
in  the  uterus  above  the  point  of  torsion. 

As  a  rule,  the  displacement  is  not  discovered  until  an  exploratory 
incision  is  made  to  remove  the  cause. 

Prolapsus  Uteri. — As  suggested  by  Berry  Hart,  prolapsus  uteri 
should  be  considered  under  the  head  of  displacement  of  the  pelvic 
floor.  The  displacement  should  be  regarded  as  a  hernia  of  the  uterus, 
adnexa,  bladder,  rectum,  and  vagina.  While  the  author  is  in  accord 
with  this  view,  the  subject  will  be  considered  with  other  displacements 
of  the  uterus.  Webster,  in  his  text-book  on  Diseases  of  Women,  holds 
that  prolapsus  of  the  uterus,  vagina,  urethra,  and  bladder  is  the  result 
of  failure  on  the  part  of  the  fascial  and  other  tissues  supporting  these 
organs  between  the  bony  walls  of  the  pelvis  to  resist  intra-abdominal 
pressure  and  gravity.  If  the  power  of  resistance  is  weakened,  or  the 
intra-abdominal  pressure  and  weight  of  the  uterus  are  increased,  or  if 
both  factors  cooperate,  prolapsus  will  occur.  Webster  takes  exception 
to  the  view  of  Hart,  who  regards  the  perineum  as  a  fixed  segment  for 
the  support  of  the  uterus,  and  of  Thomas,  who  holds  that  the  perineum 
is  a  supporting  wedge.  By  anatomical  dissections  Webster  has  demon- 
strated that  the  pelvic  fascia,  and  not  the  perineum  and  levator  ani 
muscle,  are  the  real  support. 

The  various  fascial  tissues  which  meet  in  the  perineum  and  give 
support  to  the  pelvic  viscera  are:  (1)  The  anterior  and  posterior 
triangular  ligaments.  (2)  The  visceral  layer  of  the  rectovaginal  fascia. 
(3)  The  anal  fascia.     (4)  The  deep  superficial  fascia. 

Webster  holds  that  the  perineal  muscles  are  of  little  value  as  a  support 
compared  to  the  pelvic  fascia.  In  the  absence  of  actual  rupture  of 
the  fascia,  it  is  possible  for  stretching  alone  to  so  weaken  the  support 
that  prolapsus  will  occur. 


316  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

Prolapsus  uteri  is  a  term  implying  not  only  a  descent  of  the  uterus, 
but  also  involvement  of  the  bladder,  rectum,  vagina,  and  adnexae. 
Descent  of  the  uterus  may  be  checked  at  any  point  between  the  normal 
position  and  extreme  prolapse. 

Nomenclature. — With  Webster,  the  author  will  speak  of  (1)  descensus 
uteri,  when  the  uterus  and  vaginal  walls  do  not  descend  beyond  the 
vulvar  outlet,  and  (2)  prolapsus  uteri,  when  the  uterus  and  vagina 
protrude  beyond  the  vulvar  outlet. 

Etiology. — The  most  frequent  displacement  of  the  uterus  is  descent 
or  prolapse.  In  the  Tiibingen  clinic,  prolapsus  of  the  uterus  constitutes 
12  per  cent,  of  all  tjie  pelvic  lesions,  ranking  first  in  point  of  frequency 
in  their  case  records.  The  greatest  number  occur  between  the  ages  of 
thirty  and  sixty  years.  That  they  do  not  occur  with  greater  frequency 
before  the  age  of  thirty  is  accounted  for.  by  the  fact  that  prolapsus 
uteri  is  almost  always  the  result  of  childbearing.  While  the  forces  of 
labor  weaken  the  pelvic  floor  and  the  uterine  ligaments,  it  is  usually 
not  until  the  long-continued  influences  of  intra-abdominal  pressure  and 
of  gravity  have  operated  upon  the  poorly  supported  uterus  that  the 
prolapsus  develops. 

Hence  it  follows  that  one  or  more  years  usually  succeed  childbirth 
before  the  uterus  decends  to  any  considerable  degree.  This  is  the  rule 
to  which  there  are  few  exceptions. 

The  causes  of  prolapsus  uteri  may  be  outlined  as  follows : 
Loss  of  swpioort  from  below. 
Relaxation  of  the  pelvic  floor. 
Laceration  of  the  pelvic  floor. 
Traction  from  below. 
Cystocele. 
Rectocele. 

Fibroid  of  the  cervix. 
Pressure  from  above. 
Tight-lacing. 
Visceroptosis. 

Abdominal  ascites  and  tumors. 
Straining,  as  in  lifting. 
Increased  weight  of  uterus. 
Chronic  metritis. 
Fibroids. 
Subinvolution. 
Early  pregnancy. 
Diagnosis. — The  erect  posture  of  the  patient  is  the  most  favorable 
in  recognizing  a  downward  displacement  of  the  uterus  (Fig.  31).     In 
the  recumbent  position  the  uterus  may  wholly  or  in  part  resupie  the 
normal  position.     The  erect  position  is  awkward  and  embarrassing,  and 
for  these  reasons  is  seldom  used.     With  the  patient  in  the  lithotomy 
position  the  uterus  may  be  so  manipulated  as  to  effectively  demonstrate 
the  degree  of  descensus.     Bimanual  manipulatiop,  and,  if  necessary, 
traction  upon  the  cervix  with  a  vulsellum  forceps,  wn"ll  bring  the  uterus 


MALPOSITIONS  OF  THE  UTERUS 


317 


down  to  its  maximum  degree.  Under  normal  conditions  it  is  not  possible 
to  draw  the  vaginal  portion  of  the  cervix  beyond  the  vulvar  outlet. 

Anatomical  Diagnosis. — The  diagnosis  is  almost  wholly  based  upon 
the  anatomical  findings.  It  is  at  times  possible  to  make  a  diagnosis 
from  inspection  alone. 

Inspection  of  the  vulva  may  disclose  the  uterus  and  vaginal  walls 
protruding  from  the  vulvar  outlet.  In  nearly  all  such  cases  the  perineum 
is  lacerated,  and  there  may  be  a  prolapsus  of  the  mucous  membranes 
of  the  urethra  and  rectum. 


FR. 
Urh. ' 

y.s  - 


O.E. 

Prolapse  of  the  uterus  in  an  old  woman.  Cervix  greatly  elongated.  Cystocele  (PR)  os  externum 
(0£)  protrudes  from  the  vulva.  Vesico-uterine  fold  of  peritoneum  (Evw)  lies  relatively  high.  The 
cul-de-sac  of  Douglas  (Eru)  is  very  deep.  The  urethra  (Urh)  is  in  its  normal  position.  VS,  the 
anterior  vaginal  wall;  HS,  the  posterior  vaginal  wall.     M.  Sph,  sphincter  muscle. 


Displacement  of  the  Vagina. — Inasmuch  as  the  uterus  is  seldom 
displaced  downward  without  a  primary  or  secondary  involvement  of 
the  vagina,  descensus  and  prolapsus  of  the  vagina  will  be  first 
considered. 

Descensus  Vagince. — Descensus  vaginse  implies  a  downward  displace- 
ment of  the  vagina  to  a  point  near  the  vulvar  outlet.  Preceding  the 
descent  of  the  vaginal  walls,  there  is  usually  a  relaxation  or  laceration 
of  the  pelvic  floor.  As  a  rule,  the  anterior  wall  of  the  vagina  is  first  to 
descend;  then  follows  the  uterus  as  it  is  pulled  upon  by  the  sagging  wall 
of  the  vagina,  and,  finally,  the  uterus  in  turn  carries  with  it  the  posterior 
wall  of  the  vagina.  It  is  unusual  for  the  anterior  and  posterior  walls  of 
the  vagina  to  descend  simultaneously  and  equally,  and  the  primary 
descent  of  the  posterior  vaginal  wall  is  more  unusual.  A  limited 
degree  of  descensus  vaginae  may  exist  without  displacing  the  uterus. 


318 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


The  descent  occurs  from  below  upward ;  seldom  from  above  downward 
(Fig.  208). 

Prolapsus  Vaginae. — Prolapsus  vaginae  implies  a  protrusion  of  the 
vaginal  walls  beyond  the  vulvar  outlet,  and  is  associated  with  downward 
displacement  of  the  uterus.  In  primary  descent  and  prolapse  of  the 
uterus,  the  vaginal  walls  are  inverted  from  above  downward,  there 


Fig.  203 


Complete  prolapse  of  the  uterus. 


Complete  eversion  of  the  vaginal  walls.    Hernia  of  the 
recto-uterine  space. 


being  no  pouching  of  the  vaginal  walls  as  in  secondary  prolapse  of  the 
uterus.  The  lower  segment  of  the  vaginal  wall  may  prolapse,  the 
upper  segment  invert,  and  the  intervening  one  remain  unchanged. 
The  prolapsed  anterior  vaginal  wall  pouches  into  the  vagina,  dragging 
the  bladder  with  it,  and  forming  what  is  known  as  a  c}'stocele.  The 
bladder  is  intimately  attached  to  the  anterior  wall  of  the  vagina,  so 
that  it  is  impossible  for  the  vagina  to  descend  without  carrying  the 


MALPOSITIONS  OF  THE   UTERUS 


319 


bladder  with  it.  The  vaginal  wall  loses  its  usual  elasticity,  and  becomes 
glistening,  dry,  and  leathery.  Decubitus  ulcers  may  form  and  show 
but  little  tendency  to  heal.  Between  the  posterior  wall  of  the  vagina 
and  the  rectum  no  close  attachment  exists — a  fact  which  explains  why 
in  prolapse  of  the  posterior  vaginal  wall  the  rectum  does,  not  always 
descend  with  the  vagina. 


Fig.  204 


PI.  IV. 
R. 


Total  prolapse  of  anterior  vaginal  wall.  Partial  inversion  of  posterior  vaginal  wall.  Rectum 
distended  and  crowding  the  uterus  forward.  Partial  prolapse  of  the  uterus  with  elongation  of  the 
cervix.     Cystocele.     Adh.,  adhesions.     (Tandler  and  Halban.) 


Descensus  and  prolapsus  vaginse  are  recognized  by  inspection  and 
palpation  of  the  vagina.  Holding  the  labia  apart,  the  vaginal  pouch, 
with  its  transverse  folds,  is  seen  to  bulge  into  the  introitus.  Inversion 
of  the  vagina  is  recognized  by  a  corresponding  shortening  of  the  vaginal 
wall,  together  with  a  probable  descent  of  the  uterus. 

Displacements  of  the  Uteras. — After  inspection  and  palpation  of  the 
vulva  and  vagina,  the  position  of  the  uterus  is  to  be  determined.  The 
vaginal  walls  may  be  prolapsed  to  an  extreme  degree  without  altering 
the  position  of  the  uterus,  though  this  is  rare.  In  a  prolapse  of  the 
vagina  one  expects  to  find  a  secondary  descent  of  the  uterus.  The 
descent  of  the  uterus  may  be  either  primary  or  secondary. 

Primary  Descent  mid  Prolapse. — Primary  descent  and  prolapse  of 
the  uterus  are  the  result  of  relaxed  uterine  supports,  of  added  weight 


320 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


to  the  uterus,  or  of  increase  in  the  intra-abdominal  pressure.  As  the 
uterus  descends,  the  anterior  and  posterior  walls  of  the  vagina  become 
inverted  from  above  downward,  and  near  the  outlet  of  the  vagina 
the  walls  are  relaxed.  In  exaggerated  cases  the  vaginal  walls  may  be 
completely  inverted,  thereby  permitting  the  uterus  to  protrude  beyond 
the  vulvar  outlet. 

Fig.  205   ■  '  "' 


Secondarj'  prolapsus  uteri,  vriih  elongation  of  the  cer^-ix.  Both  vaginal  walls  are  completely 
inverted.  The  cer^'ix  protrudes  from  the  \'Tjlva.  Neither  the  bladder  nor  the  rectum  is  found 
in  the  protruding  structures. 


Secondary  Descent  and  Prolapse. — Secondary  descent  and  prolapse 
of  the  uterus  follow  upon  a  primary  prolapse  of  the  vaginal  walls.  As 
the  walls  of  the  vagina  descend,  traction  is  made  upon  the  uterus  at 
the  point  of  attachment  of  the  vagina.  If  the  supports  of  the  uterus 
offer  little  or  no  resistance,  the  walls  of  the  vagina,  assisted  by  gravity 
and  intra-abdominal  pressure,  will  inaugurate  a  descent  of  the  uterus. 
If,  however,  the  normal  supports  of  the  uterus,  assisted  by  adhesions 
and  newgrowi;hs,  retard  the  descent  of  the  uterus,  there  will  usually 
follow  an  elongation  of  the  cervix  in  its  supravaginal  portion.  Further- 
more, since  the  anterior  wall  of  the  vagina  is  first  to  prolapse,  the  ante- 
rior lip  of  the  cervix  will  be  elongated  to  a  greater  degree  than  will 
the  posterior  lip.  If  there  is  a  simultaneous  prolapse  of  both  vaginal 
walls,  the  two  lips  of  the  cervix  will  be  equally  elongated.    Hence,  in 


MALPOSITIONS  OF   THE   UTERUS 


321 


secondary  prolapse  of  the  uterus  there  is  usually  an  elongation  of 
the  cervix,  while  in  primary  prolapse  there  is  no  such  change. 

In  complete  prolapsus  uteri  with  inversion  of  both  walls  of  the  vagina, 
the  cervix,  having  been  previoush'  elongated,  will  retract  more  or  less 
and  may  be  materially  shortened.  The  direction  of  the  long  axis  of 
the  uterus  varies  with  the  descent.  The  usual  position  in  descensus 
uteri,  when  the  uterus  lies  in  the  pelvis,  is  that  of  retroversion,  and 
this  position  is  exaggerated  as  the  uterus  descends. 

The  adnexse  are  drawn  down  by  the  uterus,  and  in  complete  pro- 
lapsus are  found  in  a  funnel-like  depression  formed  of  peritoneum. 


Fig.  206 


Complete  inversion  of  the  uterub. 


The  bladder  is  so  intimately  connected  with  the  anterior  vaginal 
wall  and  cervix  that  it  must  necessarily  share  in  the  displacement  of 
the  uterus.  As  the  anterior  wall  of  the  vagina  pouches  it  drags  upon 
the  base  of  the  bladder.  In  this  manner  a  cystocele  is  formed  which, 
in  complete  prolapse  of  the  vagina,  may  include  the  greater  portion 
of  the  bladder,  causing  it  to  protrude  from  the  vulvar  orifice.  The 
exact  limitations  of  a  cystocele  are  determined  by  the  catheter  or 
sound  placed  in  the  bladder.  When  the  bladder  is  distended  the  cystic 
mass  is  felt  and  seen  to  protrude  into  the  vagina;  its  outlines  can 
usually  be  determined  by  inspection. 
21 


322 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


The  rectum  is  more  loosely  connected  with  the  vaginal  wall  than 
the  bladder.  The  loose  connective  tissue  may  permit  of  a  complete 
prolapse  of  the  posterior  wall  of  the  vagina  without  displacing  the 
rectum.  More  often  there  is  a  pouching  forward  of  the  rectum  into 
the  vaginal  pouch  (rectocele).  By  direct  palpation  through  the  rectum 
the  location  and  extent  of  the  rectocele  are  determined. 


Primarj'  prolapse  of  the  uterus.     The  uterus  lies  wholly  outside  the  vulva, 
completely  inverted.     The  cervix  is  not  elongated. 


The  vaginal  walls  are 


The  anatomical  changes  occurring  in  the  prolapsed  tissues  are  largely 
the  result  of  disturbance  in  circulation,  of  exposure  to  the  influences 
of  air,  and  of  friction  of  the  thighs.  There  is  first  congestion  and 
edematous  infiltration,  this  being  followed  by  induration  (h^^jerplasia) 
of  the  tissues.  Decubitus  ulcers,  slow  in  healing,  may  form  on  exposed 
surfaces.  When  the  lips  of  the  cervix  are  retracted  by  the  vaginal 
walls,  the  exposed  mucous  membrane  of  the  cervix  may  be  transformed 
into  stratified  epithelium. 

Clinical  Diagnosis. — The  diagnosis  of  descensus  and  prolapsus  uteri  is 
seldom  difficult.  It  is  unusual  to  find  a  prolapsed  uterus  in  a  nullipara. 
Beyea  estimates  that  prolapsus  uteri  in  nulliparae  occurs  in  not  more 
than  1  per  cent,  of  all  cases.  He  reported  two  cases  and  found  sixty- 
two  others  in  the  literature. 


MALPOSITIONS  OF  THE   UTERUS 


323 


When,  upon  physical  examination,  the  pelvic  floor  is  found  relaxed 
or  lacerated,  and  there  is  also  found  a  rectocele  and  vesicocele,  it  may 
be  that  the  uterus  will  be  found  more  or  less  prolapsed.  A  positive 
diagnosis  can  only  be  made  by  locating  the  fundus  of  the  uterus  in  a 
bimanual  examination.  The  patient  being  under  anesthesia,  firm 
traction  upon  the  cervix  with  the  vulsellum  forceps  will  determine  the 
exact  extent  of  the  displacement  (Fig.  209).  The  finding  of  the  cervix 
at  a  lower  level  than  is  normal  will  not  suffice  for  a  diagnosis.  Such  a 
finding  is  frequently  due  to  an  elongation  of  the  cervix,  either  with  or 
without  a  descent  of  the  uterus.    Without  having  located  the  fundus 


Fig.  208 


Secondary  descent  of  the  uterus.  The  uterus  is  retroverted  and  lies  on  a  plane  lower  than  normal. 
The  cervix  does  not  extend  to  the  vulvar  outlet.  The  anterior  vaginal  wall  is  prolapsed  and  the 
posterior  vaginal  wall  is  partially  inverted. 


it  cannot  be  said  that  the  uterus,  as  a  whole,  has  descended.  By  a 
rectal  examination  it  is  often  possible  to  locate  the  point  of  juncture  of 
the  cervix  and  uterine  body  and  estimate,  with  some  degree  of  accuracy, 
the  length  of  the  cervix.  Measuring  the  depth  of  the  uterus  by  the 
sound  will  give  exact  information. 

It  is  more  difficult  to  determine  whether  it  is  the  supravaginal  or  the 
infravaginal  portion  of  the  cervix  that  is  elongated.  This  is  ascertained 
by  noting  the  depth  of  the  vault  of  the  vagina.  If  decreased  in  depth, 
the  supravaginal  portion  of  the  cervix  is  elongated;  if  it  remains  at  the 


324 


MALPOSITIOXS  OF  THE  GENITAL  ORGANS 


normal  level,  the  infravaginal  portion  of  the  cervix  is  elongated.  Both 
the  infravaginal  and  the  supravaginal  portions  of  the  cervix  may  be 
increased  in  length,  in  which  event  there  will  be  little  change  in  the 
depth  of  the  vault  of  the  vagina. 

When  the  uterus  is  completely  prolapsed  it  is  possible  to  approximate 
the  hands  over  and  abo^•e  the  body  of  the  uterus,  having  merely  the 
vaginal  walls  and  bladder  between  the  fingers.  By  so  doing  it  is  possible 
to  absolutely  exclude  all  other  conditions  (Fig.  211). 


Fig.  209 


Elongation  of  the  cen-Lx  with  prolapsus  uteri.  Traction  made  upon  the  cervix  by  a  ^^llsellum 
forceps  pulls  the  cer\-ix  two  inches  beyond  the  %-ulvar  outlet.  The  body  of  the  uterus  lies  within  the 
peh-is,  but  at  a  lower  level  than  normal.  The  depth  of  the  uterine  ca^-ity,  measured  by  a  sound,  is  five 
inches. 


Can  the  displacement  of  the  vagina  and  uterus  be  corrected?  This 
question  will  naturally  arise  before  the  diagnosis  is  complete.  An 
attempt  to  replace  the  uterus  may  be  made  without  anesthesia,  but 
when  there  is  much  tenderness,  or  when  great  difficulty  is  encoun- 
tered, an  anesthetic  should  be  given.  Among  the  hindrances  to  the 
replacement  of  the  uterus  may  be  mentioned  pelvic  tumors,  adhesions, 
inflammatory  exudates,  and  swelling  from  edema  and  induration  of  the 
uterus  and  vagina. 


MALPOSITIONS  OF  THE  UTERUS 


325 


While  the  clinical  symptoms  cannot  be  relied  upon  in  the  diagnosis 
of  prolapsus  uteri,  they  are  fairly  constant  and  deserve  consideration. 

Backache  is  the  most  common  complaint,  but  is  more  often  due 
to  diseases  of  the  adnex?e  and  to  inflammatory  exudates  complicating 
prolapsus. 

Feeling  of  weight,  pressure,  and  traction  is  to  be  accounted  for  by 
the  increased  size  of  the  uterus,  by  pressure  upon  neighboring  structures 
and  by  traction  upon  adhesions  and  the  natural  supports  of  the  uterus. 

Fig.  210 


Prolapsus  uteri.    The  external  os  is  lacerated  and  eroded.    On  the  side  of  the  prolapsed  uterus  is 
a  decubitus  ulcer.     (Case  of  Dr.  J.  Clarence  Webster.) 


Leucorrhea  and  menorrhagia  are  the  results  of  passive  congestion 
of  the  uterus,  which  in  turn  is  the  result  of  the  displacement. 

Sterility  is  due  to  mechanical  hindrances  and  to  complicating  lesions 
in  the  uterus  and  adnexse.  Pregnancy  in  a  prolapsed  uterus  will  either 
terminate  spontaneously  or  go  on  to  full  term.  Abortion  is  most  likely 
to  occur  about  the  fourth  month,  when  the  pregnant  uterus  can  no 
longer  be  accommodated  in  the  limited  space  of  the  pelvis.  If,  however, 
the  uterus  does  rise  into  the  abdominal  cavity  the  prolapsus  is  relieved 


326 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


for  the  period  of  pregnancy.  Involution  in  the  puerperium  is  hkely  to 
be  retarded,  and  the  lochial  discharge  may  remain  bloody  an  unusually 
long  time. 

Disturbances  of  the  bladder  functions  are  almost  constant,  and  are 
explained  by  pressure  upon  the  bladder  and  the  displacement  of  the 
bladder  and  urethra.  Retention  of  the  urine  is  possible  even  to  the 
point  of  rupture  of  the  bladder.    Cystitis  may  develop. 

The  rectal  functions  are  generally  disturbed,  though  not  to  the  extent 
and  frequency  found  with  the  bladder.  Constipation,  rectal  tenesmus, 
and  hemorrhoids  are  the  result  of  pressure  made  upon  the  rectum  by 
the  prolapsed  uterus. 

Fig.  211 


Bimanual  palpation  of  the  prolapsed  uterus. 


Differential  Diagnosis, — Prolapsus  uteri  is  most  often  confused  with 
an  elongated  cervix.  The  vaginal  portion  of  the  cervix  may  be  so 
enormously  enlarged  as  to  resemble  a  prolapsed  uterus.  The  differen- 
tial diagnosis  has  been  considered  in  a  previous  paragraph. 

Complete  prolapsus  uteri  with  atresia  of  the  cervix  may  be  mistaken 
for  an  inverted  uterus.  The  finding  of  the  fundus  will  clear  up  the 
diagnosis. 

A  large  cyst  of  the  vagina  may  protrude  from  the  vulva,  and  on 
superficial  examination  be  mistaken  for  a  prolapsed  uterus.     Such 


MALPOSITIONS  OF  THE  UTERUS 


327 


cysts  do  not  lie  in  the  median  line;  they  fluctuate,  and  are  covered 
with  thin  mucous  membrane.  A  recto-abdominal  examination,  under 
anesthesia  if  necessary,  will  enable  the  examiner  to  locate  the  body 
of  the  uterus  in  its  normal  position. 

A  pedunculated,  submucous  fibroid  protruding  into  the  vagina,  or  a 
pedunculated  fibroid  of  the  cervix,  may  be  mistaken  for  a  prolapsed 
uterus.  The  absence  of  the  external  os  in  the  advancing  body,  the 
finding  of  the  fundus  within  the  pelvis  at  its  normal  level,  and  the 
passage  of  a  sound  into  the  uterine  cavity  will  clear  the  diagnosis. 

Fig.  212 


Prolapse  of  the  third  degree.     Uterus  protruding  through  the  vulva.     Sounds  demonstrate  the 
bladder  to  be  in  complete  descent  with  the  uterus.     (Schaffer.) 


Treatment. — The  treatment  of  prolapsus  uteri  necessarily  embraces 
the  correction  of  a  relaxed  and  torn  pelvic  floor  and  vaginal  walls, 
amputation  of  an  elongated  cervix,  and  the  management  of  the  many 
complications  in  the  uterus  and  adnexse  that  are  associated  with  this 
form  of  displacement. 

Prophylaxis. — As  a  preventive  measure  the  early  repair  of  injuries  to 
the  pelvic  floor  is  of  the  highest  importance.  Indeed,  if  such  conditions 
were  not  neglected,  prolapsus  uteri  would  cease  to  occupy  such  a 
prominent  place  among  the  lesions  of  the  pelvis.  The  early  repair 
of  the  lacerated  perineum  would  eliminate  a  large  proportion  of  the 


328  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

cases,  but  by  no  means  all,  for  we  have  to  reckon  with  the  relaxed  out- 
let and  pelvic  floor,  with  the  overstretched  ligaments  of  the  uterus  and 
the  intra-abdominal  pressure. 

Modern  obstetrical  teaching  is  sufficiently  clear  in  the  emphasis  it 
places  upon  the  immediate  repair  of  the  pelvic  floor,  but  the  gynecologist 
is  chary  in  his  account  of  the  early  repair  of  the  neglected  injuries 
to  the  pelvic  floor.  The  recent  lacerations  of  the  perineum,  the  relaxed 
vaginal  walls  which  are  beginning  to  drag  upon  the  cervix,  and  the 
undue  laxity  of  the  overstretched  ligaments  which  have  failed  to  retract; 
these  shoidd  be  corrected  as  early  as  possible  after  the  completion  of 
the  puerperium. 

The  correction  of  a  prolapsed  uterus  in  the  early  stage  presents 
the  least  difficulties,  and  assures  the  best  and  most  lasting  results. 
In  the  later  stages  the  operation  is  more  complicated,  and  the  sequential 
results  observed  in  the  uterus  and  in  the  neighboring  organs  may  make 
full  restoration  to  health  impossible.  It  therefore  follows  that  the  earlier 
the  operation  the  better  the  results. 

The  following  precautions  should  be  observed: 

A.  In  labor: 

1.  Do   not   encourage   patients   to   bear   down   until   nature 

excites  the  inclination. 

2.  Do  not  apply  forceps  until  the  cervix  is  fully  dilated. 

3.  Avoid,  as  far  as  possible,  all  means  of  hastening  the  second 

stage  of  labor. 

4.  Repair  all  wounds  of  the  cervix  and  pelvic  floor  immediately 

after  labor. 

B.  During  the  puerperium: 

1.  Keep  the  patient  in  bed  ten  to  fourteen  days. 

2.  Prevent  overdistention  of  the  bladder  and  constipation. 

3.  Examine  patients  at  the  end  of  six  weeks  and  make  the 

necessary  repair  of  existing  injuries. 

Preliminary  Treatment. — Before  resorting  to  operation  certain  steps 
should  be  taken  in  preparation  for  operation.  If  the  general  health 
of  the  individual  is  such  as  to  render  an  operation  hazardous,  time 
should  be  taken  to  restore  these  conditions  so  far  as  it  is  possible. 
Furthermore,  there  are  local  conditions  which  demand  attention  before 
operating.  The  pelvic  congestion,  so  commonly  associated  with  pro- 
lapsus, should  be  relieved,  and  ulcers  on  the  vaginal  walls  should  be 
healed. 

General  Treatment  and  Hygiene. — Careful  attention  should  be  directed 
to  rest,  exercise,  baths,  diet,  and  the  care  of  the  bowels.  All  constric- 
tion about  the  waist  line  should  be  removed  and  a  straight  front  corset 
or  abdominal  binder  worn  to  give  support  to  the  abdominal  .organs. 
Constitutional  treatment  should  be  given  when  indicated. 

Replacement  of  the  Uterus. — To  relieve  the  pelvic  congestion  and 
ulcerations  of  the  vaginal  walls  and  cervix,  it  is  essential  to  first  replace 
the  uterus  and  to  keep  it  in  place  by  a  temporary  support.  All  con- 
stricting clothing  is  removed  from  the  waist,  the  bowels  and  bladder 


MALPOSITIONS  OF  THE  UTERUS 


329 


are  emptied^  and  the  patient  put  in  the  knee-elbow  position.  The 
uterus  is  then  grasped  by  the  hand  and  gently  forced  into  the  vagina, 
following  the  line  of  least  resistance.  Unless  adhesions  exist  or  the 
size  of  the  uterus  will  not  permit  of  its  free  mobility,  the  organ  readily 
assumes  its  normal  position.  It  is  rarely  necessary  to  give  an  anes- 
thetic. In  acute  displacements  the  associated  congestion  and  edema 
may  greatly  enlarge  the  protruding  uterus.  In  this  event  it  may  be 
necessary  to  elevate  the  hips  and  apply  hot  fomentations  to  the  pro- 
truding mass  for  several  hours  before  attempting  to  effect  a  replacement. 
As  a  rule,  the  patient  herself  is  able  to  replace  the  uterus  by  lying 
in  the  knee-elbow  or  lithotomy  position  and  forcing  the  projecting  mass 
back  with  her  fingers  (Fig.  213). 


Fig.  213 


Patient  assumes  the  knee-chest  position  and  pushes  the  prolapsed  uterus  high  into  the  vagina. 

Tampons. — To  temporarily  hold  the  uterus  at  its  normal  level,  two 
or  more  lambs'  wool  tampons  should  be  inserted  high  in  the  vagina 
while  the  patient  is  in  the  knee-elbow  position.  These  tampons  should 
be  applied  daily,  and  if  difficulty  is  experienced  in  retaining  the  tam- 
pons in  the  vagina,  a  T-binder  should  be  worn  over  a  vulvar  pad  of 
gauze. 

Vaginal  Douches. — In  order  to  protect  the  vaginal  surfaces  from 
irritating  discharges,  a  mild  antiseptic  vaginal  douche  should  be  given 
once  or  twice  daily.  For  this  purpose  the  author  usually  prescribes 
lysol  solution,  1  to  1000.  When  tampons  are  worn  the  douche  is  given 
before  replacing  the  tampon. 

Treatment  of  Ulcers  and  Erosions. — As  a  rule,  these  lesions  will  heal 
spontaneously  if  the  uterus  is  replaced  and  the  vagina  kept  clean  by 


330  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

douches.  When  the  healing  is  slow  the  ulcers  may  be  stimulated  by  the 
application  of  a  10  per  cent,  silver  nitrate  solution,  the  application 
being  made  twice  a  week. 

Pessaries.- — After  these  preliminary  measures  have  been  employed, 
with  the  result  that  congestion  has  been  relieved  and  ulcerations  have 
healed,  it  is  then  necessary  to  provide  a  more  permanent  support. 
It  is  not  always  advisable  to  operate  and  not  all  patients  will  accept 
such  advice.  When  the  patient  is  old  or  afflicted  with  diabetes,  disease 
of  the  lungs,  heart,  or  kidney,  or  with  any  other  disease  that  will  render 
an  operation  hazardous,  the  next  step  will  be  to  adjust  a  suitable  pes- 
sary. This  is  by  no  means  an  easy  problem.  The  ordinary  pessaries, 
such  as  the  Hodge  or  Albert-Smith,  will  be  useless.  When  the  pelvic 
floor  is  fairly  intact  it  may  be  possible  to  adjust  a  ring  pessary,  but 
in  the  majority  of  instances  nothing  will  serve  the  purpose  short  of 
a  cup  and  stem  pessary  attached  to  an  abdominal  support  (Fig.  214). 
This  pessary  should  be  removed  at  night  and  the  ring  or  cup  should 
be  cleansed  daily;  the  vagina  also  should  be  irrigated  daily,  to  prevent 
the  development  of  ulcers. 


Mcintosh  uterine  support  for  prolapsus. 

Colpeuryriter. — When  the  pessary  causes  pain  and  discomfort  a 
colpeurynter  (Braun)  will  provide  relief.  The  same  precautions  should 
be  taken  in  the  wearing  of  a  colpeurynter  as  in  the  wearing  of  a  pessary. 
If  the  vaginal  walls  and  cervix  become  irritated  the  colpeurynter  should 
be  anointed  with  zinc  oxide  ointment. 

Technic  of  Operation. — To  successfully  restore  a  prolapsed  uterus, 
due  regard  must  be  paid  to  all  associated  lesions,  otherwise  the  results 
will  not  be  satisfactory.  Not  only  must  the  uterus  be  permanently 
restored  to  the  normal  position,  and  in  such  manner  as  to  avoid  any 
possible  interference  with  the  normal  functions  of  the  pelvic  organs, 
but  the  cervix,  vaginal  walls,  and  pelvic  floor  will  usually  demand  the 
attention  of  the  surgeon  if  the  uterus  is  to  remain  in  its  corrected 
position.  This  requires  plastic  surgery  on  the  pelvic  floor,  to  be  followed 
during  the  same  anesthetic  by  the  abdominal  work.  The  precaution 
is  taken  to  make  a  complete  change  of  gown,  gloves,  instruments,  and 
surgical  appliances  in  the  interim  between  the  vaginal  and  abdominal 
operations. 


MALPOSITIONS  OF  THE  UTERUS  331 

The  following  is  the  usual  order  of  procedure: 

1.  Curettage. 

2.  Anterior  colporrhaphy  when  there  is  relaxation  of  the  anterior 
wall  of  the  vagina. 

3.  Amputation  of  the  cervix  when  it  is  elongated  or  deeply  lacerated. 

4.  Colpoperineorrhaph}'. 

5.  Shortening  of  the  round  ligaments  or — 

6.  Amputation  of  the  body  of  the  uterus,  and  fixation  of  the  stump 
to  the  abdominal  wall. 

It  will  be  observed  that  the  author  has  not  advised  fixation  of  the 
body  of  the  uterus  to  the  abdominal  or  vaginal  walls,  for  reasons  which 
will  appear  later. 

1.  Curettage. — The  endometrium  is  commonly  hypertrophied  in  pro- 
lapsus and  gives  rise  to  leucorrheal  discharges.     (See  page  126.) 

2.  Anterior  Colporrhaphy.     (See  page  294.) 

3.  Amputation  of  the  Cervix. 

4.  Colpoperineorrhaphy.     (See  page  763.) 

5.  Shortening  of  the  Round  Ligaments.    (See  page  368.) 

6.  Amputation  of  the  Body  of  the  Uterus  and  Fixation  of  the  Stump 
to  the  Abdominal  Wall,  a  procedure  credited  to  Baldy. 

The  removal  of  the  body  of  the  uterus,  followed  by  the  fixation  of 
the  cervical  stump  to  the  abdominal  wall,  is  unquestionably  the  best 
procedure  when  there  is  great  relaxation  of  the  uterine  supports  and 
the  patient  is  incapable  of  childbearing,  either  for  reasons  of  advanced 
age  or  for  anatomical  conditions,  such  as  uterine  fibroids  and  chronic 
metritis. 

Baldy  Operation. — After  a  supravaginal  amputation  of  the  uterus,  the 
cervical  stump  is  fixed  to  the  abdominal  wall  at  the  lower  end  of 
the  incision.  Two  silkworm-gut  sutures  are  used  for  this  purpose. 
They  are  made  to  transfix  the  cervical  stump  from  side  to  side  and  are 
brought  through  the  peritoneum,  muscle,  and  deep  fascia  on  either 
side  of  the  abdominal  incision.  They  are  then  securely  tied  and  the 
ends  of  the  sutures  cut  close  to  the  knots,  after  which  the  abdominal 
incision  is  closed  in  the  usual  manner.  Before  closing  the  abdomen 
care  must  be  exercised  in  coapting  all  peritoneal  surfaces  about  the 
cervical  stump  and  broad  ligaments.  This  is  done  with  a  continuous 
catgut  suture. 

Baldy  does  not  now  bury  the  fixation  sutures,  but  passes  them  com- 
pletely through  the  abdominal  wall,  as  in  the  operation  of  ventral 
fixation,  and  denudes  the  under  surface  of  the  abdominal  wall  where 
it  comes  in  contact  with  the  cervical  stump,  for  fear  the  support  may 
be  weakened  by  the  stripping  of  the  peritoneum. 

The  author  does  not  favor  vaginal  hysterectomy,  total  abdominal 
hysterectomy,  or  vaginal  fixation  of  the  uterus. 

Results  in  Operations  for  Prolapsus  Uteri. — From  a  large  number  of 
home  and  foreign  clinics  the  following  statistics  have  been  obtained: 
In  1000  plastic  operations  upon  the  cervix,  vaginal  walls,  and  perineum 
there  has  been  no  return  of  the  prolapsus  after  many  years  in  70  per 


332 


MALPOSITIONS  OF  THE  <JENITAL  ORGANS 


cent,  of  the  cases.  Of  the  30  per  cent,  of  faihires  only  5  per  cent,  were 
complete.  The  recurrences  were  largely  ascribed  to  subsequent  chikl- 
bearina;. 


Baldy  operation  for  prolapsus  uteri.  Body  of  uterus  amputated.  Non-absorbable  sutures  are 
passed  through  the  abdominal  -nail  and  transfix  the  stump  of  the  cervix.  Under  surface  of  the 
abdominal  wall  denuded  to  insure  firm  fixation  of  stump. 


Fig.   216 


Baldy.  operation  for  prolapsus  uteri.  Stump  of  cervix  fixed  to  abdominal  wall  by  non-absorb- 
able sutures  passed  through  abdominal  wall  and  stump  of  cervix.  Peritoneum  stitched  about 
attachment  of  cervix  to  the  abdominal  wall. 


MALPOSITIONS  OF  THE   UTERUS  333 

Herff  obtained  "relatively  good  results"  in  78.1  per  cent,  of  his  cases 
of  partial  prolapsus  in  which  only  plastic  operations  were  performed; 
when  vetrofixation  was  done  in  addition  to  the  plastic  operations,  there 
were  76.9  per  cent,  of  recoveries,  and  when  the  prolapsus  was  extreme, 
there  were  75  per  cent,  of  recoveries. 

Dohrn  operated  on  65  cases  of  prolapsus  by  the  Hegar  plastic  opera- 
tion and  obtained  the  following  results: 

28  cases  with  43  per  cent,  of  good  remote  results; 

13  cases  with  20  per  cent,  of  slight  recurrences; 

24  eases  with  37  per  cent,  of  marked  recurrences. 

Winter  records  37  operated  cases  of  prolapsus  uteri,  with  the  following 
results : 

31  cases  with  83.8  per  cent,  of  good  remote  results; 

5  cases  with  13.5  per  cent,  of  partial  recurrences; 

1  case  of  complete  recurrence. 

Baatz  operated  on  36  cases  which  had  passed  the  climacterium, 
doing  plastic  procedures  combined  with  vaginofixation,  with  76.3  per 
cent,  of  good  remote  results. 

The  cases  of  Winter  combined  plastic  operations  w^ith  vaginal  fixa- 
tion, ventrofixation,  and  the  Alexander- Adams  operation.  Winter  had 
but  one  recurrence  in  21  cases  of  prolapsus  plus  retroversion  in  which 
the  plastic  operations  were  combined  with  vaginofixation. 

When  total  extirpation  was  carried  out  for  relief  from  complete 
prolapse  of  the  uterus  and  vaginal  walls,  Bumm  obtained  complete 
relief  from  all  functional  disturbances  in  30  cases  out  of  43,  and  in 
only  3  cases  was  there  no  improvement  in  the  ability  of  the  patients 
\o  work. 

Prolapse  of  the  Pregnant  Uterus. — A  moderate  degree  of  descent 
of  the  uterus  is  common  in  early  pregnancy,  but  complete  prolapse  of 
the  pregnant  uterus  is  rarely  seen.  Furthermore,  a  moderate  descent 
of  the  pregnant  uterus  does  not  seriously  influence  pregnancy  or 
delivery,  but  a  complete  prolapse  of  the  pregnant  uterus  has  never 
been  seen  beyond  the  seventh  month  of  gestation. 

Time  of  Occurrence. — Nulliparae  rarely  have  a  prolapsed  uterus. 
The  condition  is  usually  seen  in  women  who  have  borne  one  or  more 
children. 

Degree  of  Prolapsus. — The  extent  to  which  the  pregnant  uterus  may 
prolapse  varies  from  a  slight  descensus  to  a  complete  delivery  of  the 
gravid  uterus.  Several  cases  are  recorded  in  which  the  pregnant  uterus 
reached  to  the  level  of  the  knees. 

Tissue  Changes  in  a  Prolapsed  Uterus  Which  Lessen  the  Chances  of 
Pregnancy. — Pregnancy  is  not  likely  to  occur  in  a  prolapsed  uterus 
where  the  vaginal  walls  protrude,  the  cervix  is  greatly  elongated,  the 
lips  of  the  cervix  are  eroded  or  ulcerated,  the  cervical  canal  plugged  with 
mucus,  the  endometrium  and  uterine  musculature  thickened  through 
hyperplastic  changes,  the  tubes  and  ovaries  displaced  and  their  struc- 
ture altered  through  persistent  passive  congestion.  These  conditions 
are  common  to  prolapsus  of  long  standing. 


334  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

Events  following  upon  Pregnancy  in  a  Prolapsed  Uterus. — 1.  In  mod- 
erate degrees  of  prolapse,  the  uterus  rises  out  of  the  pelvis  in  the  fourth 
month  of  gestation^  and  for  the  remaining  months  of  gestation  the  dis- 
placement is  corrected  only  to  return,  and  possibly  in  an  exaggerated 
state,  in  the  puerperium. 

2.  In  extreme  prolapsus  and  when  the  uterus  is  fixed  in  the  pelvis, 
spontaneous  reposition  of  the  uterus  is  impossible.  Either  the  pregnancy 
will  terminate  before  term  or  the  pregnant  uterus  must  be  replaced  by 
bimanual  manipulations  or  by  operative  interference.  As  a  rule,  the 
pregnancy  will  be  terminated  in  the  early  weeks  of  gestation. 

3.  When  the  pregnancy  is  interrupted  spontaneously  there  is  usually 
an  incomplete  emptying  of  the  uterus,  due  to  the  faulty  contractions 
of  the  uterus  and  to  the  elongated  cervix. 

4.  Puerperal  and  postabortive  infections  are  common  because  of  the 
ineffectual  emptying  of  the  uterus,  the  necessity  for  operative  inter- 
ference, and  the  occasional  presence  of  ulcers  of  the  cervix. 

5.  Labor  is  retarded  by  faulty  uterine  contractions  and  the  presence 
of  a  rigid,  elongated  cervix.  The  resistance  of  the  cervix  may  be  so 
great  as  to  result  in  a  spontaneous  laceration  of  the  uterus. 

Treatment. — The  following  propositions  may  be  laid  down  as  guides 
for  the  management  of  these  cases: 

1.  In  descent  of  moderate  degree  no  treatment  may  be  called  for. 

2.  In  the  early  months  of  pregnancy,  when  more  or  less  distress  is 
occasioned  by  a  sagging  uterus,  a  suitable  pessary  may  be  worn  or  the 
patient  enjoined  to  rest  in  the  recumbent  posture  for  several  hours 
daily.  All  unusual  exertion  is  prohibited,  and  the  dress  must  be  free 
from  constriction  and  traction  at  the  waist  line. 

3.  In  acute  prolapse  of  the  pregnant  uterus  no  time  should  be  lost  in 
replacing  the  uterus  by  taxis,  and  this  must  be  followed  by  a  prolonged 
rest  in  bed. 

4.  In  retarded  labor  due  to  a  long,  rigid  cervix  a  bilateral  incision 
should  be  made  in  the  cervix  and  the  child  delivered  by  forceps  or  by 
version.  Vaginal  or  abdominal  Cesarean  section  may  be  performed  in 
selected  cases. 

5.  If  the  cervix  presents  at  the  vulvar  outlet  during  the  puerperium, 
an  antiseptic  vulvar  pad  should  be  worn  to  prevent  sepsis.  The  elongated 
cervix  of  the  pregnant  uterus  has  been  amputated  without  interrupting 
pregnancy. 

Inversion  of  the  Uterus. — Definition. — Inversion  of  the  uterus  is  the 
partial  or  complete  turning  inside  out  of  the  uterus. 
Etiology. — I.  Puerperal  causes: 

1.  Short  cord. 

2.  Cord  -^Tapped  around  the  neck  of  the  child. 

3.  Forcible  expression  of  the  placenta. 

4.  Traction  on  the  cord. 

5.  Rapid  labor. 

6.  Uterine  inertia. 


INVERSION  OF  THE   UTERUS 


335 


II.  Non-puerperal  causes: 

1.  Pediculatated  submucous  fibroids  attached  to  the  fundus. 

2.  Unknown    conditions. 

Puerperal  inversion  is  by  far  the  most  common  form.  It  occurs  in 
the  puerperium  nine  times  more  frequently  than  at  all  other  times. 

Traction  upon  the  cord  in  retained  placentae  is  the  usual  way  in 
which  the  accident  occurs  (Figs.  217  and  218). 


Fig.  217 


Fig.  218 


'Beginning  inversion  of  uterus,  placenta 
attached.  (Modified  from  Ribemont-Des- 
saignes  and  Lepage.) 


Cup-shaped  depression  of  fundus.     (Modified 
from  Ribemont-Desaignes  and  Lepage.) 


In  192,000  labors  at  the  Rotunda  Hsopital,  in  Dublin,  but  one  case 
is  reported.  Kehrer's  estimate  is  1  in  2000  labors.  The  one  essential 
condition  in  all  inversions  of  the  uterus  is  atony  of  the  musculature 
in  some  part  of  the  uterine  body.  Predisposing^  factors  to  atony  of 
the  uterus  are  frequent  childbearing,  protracted  labors,  hydramnios, 
twin  pregnancy,  precipitate  labors,  and  repeated  miscarriages.  With 
these  conditions  operating  to  fatigue  and  relax  the  uterine  musculature, 
it  needs  only  such  procedures  as  traction  upon  the  cord  and  compression 
of  the  fundus  to  effect  an  inversion. 

Spontaneous  inversion  may  occur  during  or  immediateh'  following 
the  third  stage  of  labor,  the  mechanism  being  not  unlike  that  of  intus- 
susception of  the  bowels.  Of  100  cases  of  inversion  of  the  uterus 
collected  by  Beckmann,  54  were  spontaneous,  21  were  directly  caused 


336 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


by  traction  upon  the  cord,  and  25  were  from  unknown  causes.  Of  the 
spontaneous  cases  many  were  accounted  for  by  the  presence  of  short 
cords  or  cords  twisted  about  the  neck  of  the  fetus.  Immediately 
upon  expulsion  of  the  child,  a  vacuum  is  created  in  the  uterus,  and  if, 
in  addition,  there  is  atony  of  the  fundus,  the  intra-abdominal  pressure 
may  produce  an  inversion. 


Fig.  219 


.-^^ 


The  inverted  uterus  U,  lying  in  the  vagina  V,  is  cut  open  to  show  the  peritoneal  sac,  which  does 
not  contain  the  ovaries  O,  O.  Bristles  are  passed  into  the  uterine  orifice  of  the  tubes.  6,  broad  liga- 
ment; r,  r,  round  ligament;  T,  T,  tubes.     (Hart  and  Barbour.) 

It  is  difficult  to  account  for  inversions  occurring  late  in  the  puer- 
perium.  Those  due  to  tumor  formations  in  the  body  of  the  uterus 
are  of  rare  occurrence.  Such  tumors  operate  first  by  weakening  the 
uterine  wall,  and,  second,  by  making  traction  upon  the  atonic  area. 
Pedunculated  fibroids  arising  from  the  fundus  are  forced  through  the 
cervix  into  the  vagina  by  the  contractions  of  the  uterus.  If  there  is 
relaxation  of  the  uterine  wall  at  the  point  of  attachment,  this  action 
may  cause  an  inversion  of  the  fundus. 

Olshausen  reported  a  case  of  inversion  in  a  girl,  aged  eighteen  years. 
There  was  no  assignable  cause.  This  is  one  of  the  few  cases  of  sponta- 
neous inversion  occurring  independent  of  labor  and  newgrowths. 

Anatomical  Diagnosis. — Three   grades   of   inversion  are  recognized: 

1.  When  the  fundus  lies  within  the  uterine  cavity. 

2.  When  the  fundus  lies  within  the  vagina. 

3.  When  the  entire  uterus  protrudes  from  the  vulva. 

In  the  depression  formed  by  the  inverted  fundus  are  found  the 


INVERSION  OF  THE   UTERUS 


337 


tubes,  ovarian  ligaments,  and  part  of  the  round  and  broad  ligaments. 
The  ovaries  are  rarely  found  within  the  depression.  The  mucosa, 
covering  that  portion  of  the  inverted  fundus  lying  within  the  vagina 
and  external  to  the  vulva,  undergoes  retrogressive  changes.  In  the 
beginning  there  is  marked  congestion;  later  erosions  and  true  ulcers  may 
develop,  and  the  covering  of  columnar  epithelium  may  be  converted 
into  many  layers  of  stratified  squamous  cells. 

Sloughing  and  gangrene  of  the  inverted  uterus  may  result  from  inter- 
ference with  the  circulation. 


Fig.  220 


Fig.  221 


Partial  inversion  of  the  uterus;  the  inverted 
fundus  lies  within  the  cavity  of  the  uterus. 


The  uterus  is  divided  by  a  septum  from  the 
fundus  to  the  internal  os. 


Following  the  congestion  of  the  inverted  body  is  an  enlargement 
of  the  uterus  from  hyperplasia,  which,  when  of  long  standing  and  far 
advanced,  may  prevent  replacement  of  the  inverted  fundus. 

From  the  tubes  infections  may  travel  to  the  ovary,  pelvic  connec- 
tive tissue,  and  peritoneum.  Adhesions  may  bind  together  the  tubes, 
ovaries,  and  coils  of  intestines  within  the  funnel-shaped  depression. 

Clinical  Diagnosis. — The  diagnosis  can  only  be  made  with  certainty 
by  a  physical  examination.  Subjective  signs  awaken  no  more  than  a 
suspicion  of  the  accident.  The  inversion  may  take  place  suddenly  or 
slowly,  and  is  referred  to  as  acute  or  chronic.  There  is  a  sensation 
of  something  giving  way  in  the  pelvis,  and  this  is  immediately  followed 
by  hemorrhage.  The  loss  of  blood  may  result  fatally,  or  may  be  limited 
in  amount  and  merely  prolong  the  menstrual  flow.  In  the  intervals 
of  the  bloody  flow  there  is  a  profuse  serous  or  seropurulent  discharge. 
22 


338 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


Partial  inversion  may  occasion  no  symptoms  and  may  escape  notice. 
The  functions  of  the  bowel  and  bladder  are  disturbed,  and  general 
physical  exhaustion  follows. 

Under  favorable  conditions  for  making  a  bimanual  examination  it 
is  possible  to  demonstrate,  by  the  hand  over  the  abdomen  or  in  the 
rectum,  the  absence  of  the  fundus  and  in  its  place  a  funnel-shaped 
depression.  By  the  fingers  in  the  vagina  the  inverted  fundus  is  found 
to  bulge  into  the  cavity  of  the  uterus,  into  the  vagina,  or  beyond  the 
vulvar  outlet.  A  sound  placed  within  the  bladder  may  assist  as  a 
guide  in  the  bimanual  examination.  The  finger  in  the  rectum  may  be 
made  to  meet  the  sound  in  the  bladder  or  the  hand  on  the  abdomen, 
thereby  demonstrating  the  absence  of  the  uterine  body.  In  the  pro- 
truding fundus  are  seen  the  tubal  openings,  there  being  no  external  os. 
When  the  inversion  is  not  complete,  the  cervix  may  form  a  contraction 
ring  about  the  presenting  fundus. 


Fig.  222 


Fig.  223 


Partial   inversion    of   uterus.     Modified    from 
Ribemont-Dessaignes  and  Lepage.) 


Complete  inversion  of  uterus.     (Modified  from 
Ribemont-Dessaignes  and  Lepage.) 


By  drawing  upon  the  fundus  with  one  hand,  the  fingers  of  the  other 
hand  in  the  rectum  may  be  hooked  over  the  margin  of  the  funnel- 
shaped  depression^ 

A  sound  passed  into  the  vagina  and  between  the  protruding  fundus 
and  cervix  will  extend  a  limited  distance,  and  equally  so,  around  the 
entire  circumference.    In  puerperal  inversion  the  free,  rounded,  bleeding 


IXVERSIOX  OF   THE   UTERUS 


339 


Fig.  224 


mass,  with  its  soft,  shaggy  surface  protruding  into  the  vagina,  should 
suffice  for  a  diagnosis  when  associated  with  the  disappearance  of  the 
usual  abdominal  tumor. 

DifEerential  Diagnosis.  —  Pedunculated 
fibroids  and  poh-ps  lying  within  the  vagina 
are  to  be  differentiated  from  inversion  of 
the  second  degree  by  locating  the  fundus 
of  the  uterus  within  the  pelvis  by  means 
of  a  recto-abdominal  examination;  second, 
by  passing  a  sound  into  the  uterus  and 
finding  the  cavity  of  normal  or  increased 
depth;  third,  by  the  absence  of  tubal  open- 
ings in  the  protruding  mass. 

Submucous  polyps  and  fibroids  lying 
within  the  cavity  of  the  uterus  show,  by 
the  passage  of  the  sound,  an  increase  in  the 
depth  of  the  cavity  of  the  uterus,  and  by 
a    recto-abdominal    or    vagino-abdominal       complete  inversion  of  the  uterus. 


Fig.  225 


Inverted  uterus.     Recto-abdominal  examination  in  which  the  finger  in  the  rectum  demonstrates 
the  absence  of  the  fundus. 


examination  the  fundus  is  located  within  the  pelvis.  Care  must 
be  taken  in  passing  the  sound  that  the  growth  does  not  obstruct 
the  passage  of  the  instrument,  giving  the  impression  that  the  uterine 
cavitv  is  shortened. 


340 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


A  partially  divided  uterus  with  a  depression  in  the  fundus  may,  in 
the  passage  of  the  sound  and  palpation  of  the  fundus,  suggest  a  partial 
inversion.     (See  Figs.  220  and  221.) 

Submucous  fibroids  with  partial  inversion  may  not  be  recognized 
from  a  simple  inversion  before  operating  for  the  removal  of  the  tumor. 

Prolapsus  uteri  is  distinguished  from  an  inversion  by  the  obliteration 
of  the  vaginal  fornices,  by  finding  the  external  os  at  the  bottom  of  the 
protruding  mass,  and  by  the  absence  of  a  cup-shaped  depression  in 
the  fundus.  A  sound  passed  through  the  cervix  will  sink  to  the  depth 
of  the  normal  uterine  cavity. 


Fig.  226 


Fig.  227 


Fig.  226. — Cervical  polyp,  possible  to  mistake  for  an  inverted  fundus.  The  differential  diagnosis 
is  made  by  passing  a  sound  into  the  uterine  cavity  and  by  locating  the  fundus  in  a  bimanual  exami- 
nation. 

Fig.  227. — Cervical  polyp  with  atresia  of  the  cervix.  A  sound  cannot  be  passed  into  the  uterus, 
but  the  fundus  is  located  within  the  pelvis  by  a  conjoined  examination. 


Treatment. — Prophylaxis. — Traction  on  the  cord,  in  the  effort  to 
deliver  the  placenta,  and  forcible  expression  of  the  placenta  by  the 
Crede  method,  give  rise  to  the  larger  number  of  inversions.  So  far  as 
concerns  prophylaxis  it  need  only  be  mentioned  that  such  practices 
should  be  conducted  with  caution. 

Reduction  by  Taxis. — The  method  of  manual  reduction  is  adapted 
to  cases  of  acute  postpartum  inversion,  and  should  be  instituted  at  the 
earliest  possible  moment. 

The  methods  of  taxis  differ  according  to  the  obstacles  to  be  overcome. 
If  the  cervix  does  not  form  too  tight  constriction  of  the  protruding 


INVERSION  OF  THE  UTERUS 


341 


fundus  the  best  procedure  is  to  push  steadily  and  firmly  upon  the 
most  prominent  portion  with  the  conated  hand,  until  he  fundus  has 
been  repkced.    In  cases  of  longer  standing  the  protrudmg  body  may 


Fig.  228 


Reduction  by  taxis   of  an  inverted  uterus. 


Fig.  229 


Reduction  by  taxis  of  an  inverted  uterus. 


342 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


be  reduced  in  size  by  compressing  the  body  firmly  with  the  hand, 
then  to  so  conduct  the  manipulations  as  to  return  the  body  from 
above  downward. 

Noeggerath's  method  consists  in  pushing  alternately  from  side  to 
side,  thereby  delivering  one  horn  at  a  time. 

There  is  danger  in  prolonged  taxis,  hence  judgment  should  be  exer- 
cised in  determining  the  time  limit  in  its  employment.  Recurrence 
should  be  guarded  against  by  packing  the  uterus  with  antiseptic  gauze, 
which  may  be  removed  at  the  end  of  twenty-four  hours. 

When  submucous  tumors  are  associated  with  inversion,  it  is  rare 
that  the  fundus  fails  to  return  to  its  normal  position  after  enucleation 
of  the  tumor  growth. 


Fig.  230 


Fig.  231 


Reduction  of  an  inverted  uterus.      Modified  from  Ashton. 
The  cervical  rim  is  grasped  by  bullet  forceps  Interrupted  sutures  of  No.   2  chromic  cat- 


and  a  median  incision  made  through  the  cervical 
rim,  of  sufficient  length  to  permit  of  the  reduc- 
tion of  the  fundus. 


gut  are  placed  in  the  cervical  incision.  These 
are  tied  and  the  cavity  of  the  uterus,  cervix, 
and  vagina  are  packed  with  iodoform  gauze. 


Long-standing  cases  of  inversion  are  rarely  corrected  by  taxis,  and, 
as  a  rule,  demand  operative  interference. 

In  these  cases  it  is  well  to  first  try  manual  reduction,  but  failing  in 
this,  operative  means  should  be  resorted  to.  Since  injury  may  be 
done  by  prolonging  the  efforts  at  taxis,  no  time  should  be  wasted  on 
mechanical  devices  which  were  recommended  in  the  past  years. 

Operations  Devised  for  the  Correction  of  Inversion  of  the  Uterus. — 
Dilatation  and  Incision  of  ike  Constricting  Ring,  followed  hy  Manual 
Re-placement  of  the  Fundus. — This  method  is  the  operation  of  choice 


INVERSION  OF  THE   UTERUS 


343 


when  it  can  be  effectively  carried  out.  The  effort  should  first  be  to 
dilate  the  constricting  ring,  and  failing  to  do  so  to  a  degree  that  will 
permit  of  reduction  of  the  fundus  by  taxis,  the  ring  should  be  incised 
on  either  side.  Following  the  reduction  of  the  fundus,  the  uterus  is 
packed  with  gauze  and  the  incision  in  the  ring  closed  with  chromic 
catgut. 


Fig.  232 


Fig.   233 


Amputation  of  the  inverted  fundus. 
Bullet  forceps  are  made  to  grasp  the  fundus  The  body  of  the  uterus  is  di\aded  into  two 

and  cervical  rim.  lateral  halves  as  far  as  the  internal  os.     Trac- 

tion is  made  outward  on  either  half  by  means 
of  bullet  forceps. 

The  operation  devised  by  Kiistner  consists  of  the  following  steps: 

Step  1. — A  wide  transverse  incision  is  made  through  the  cul-de-sac 
of  Douglas  into  the  peritoneal  cavity. 

Step  2. — ^The  finger  is  inserted  into  the  inversion  funnel  of  the 
uterus  and  all  adhesions  are  severed. 

Step  3. — A  median  incision  is  made  through  the  posterior  wall  of 
the  uterus.  This  incision  extends  from  a  point  about  2  cm.  below  the 
inverted  fundus  to  a  point  2  cm.  above  the  external  os. 

Step  4. — The  inverted  fundus  is  replaced  by  pressure,  with  the 
thumb  upon  the  fundus,  while  the  funnel  is  steadied  by  the  index  finger 
inserted  through  the  incision  in  the  cul-de-sac  of  Douglas. 

Step  5. — After  replacing  the  fundus  the  uterine  incision  is  sutured 
in  two  layers  passed  on  the  peritoneal  side. 

Step  6. — The  cul-de-sac  of  Douglas  is  closed  with  sutures. 


344 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


A  preexisting  infection  may  render  such  conservative  operations  as 
the  above  dangerous.  In  such  an  event,  when  taxis  fails  to  reduce  the 
inversion,  the  uterus  should  be  removed  by  the  vaginal  route. 

Vaginal  Amimtatioii  of  the  Uterus. — Traction  is  made  upon  the 
inverted  fundus  by  the  gloved  hand.  The  constricting  ring  is  exposed 
by  a  posterior  and  two  lateral  retractors.  The  constricting  ring  is 
incised  deeply  anteriorly  and  posteriorly.  Three  stout,  silk  ligatures 
are  passed  from  before  backward,  transfixing  the  stump  of  the  uterus 
at  a  point  below  the  constricting  ring. 


Fig.  234 


Fig.  235 


The  broad  ligament  and  tube  are  ligated 
on  either  side. 


Either  half  of  the  inverted  uterus  is  amputated 
at  the  internal  os  and  transverse  sutures  of 
chromic  catgut  are  placed  in  the  cervical  stump. 


The  peritoneum  is  now  opened  in  front  and  behind  and  the  uterine 
arteries  ligated  with  plain  catgut  No.  3. 

The  amputation  is  made  with  a  knife  immediately  below  the  trans- 
fixation  sutures.  These  sutures  must  be  firmly  held  by  an  assistant 
while  the  amputation  is  made  to  prevent  the  stump  from  retracting. 
The  ligatures  are  tied  after  the  amputation  is  completed  and  additional 
sutures  are  placed,  if  required.  The  stump  is  then  allowed  to  retract 
through  the  cervix. 

The  vagina  is  packed  with  iodoform  gauze,  which  may  be  removed 
at  the  end  of  forty-eight  hours. 

Vaginal  Panhysterectomy. — It  is  seldom  necessary  to  remove  the 
entire  uterus,  but  when  malignant  tumor  formations  complicate  the 
inversion  this  radical  measure  is  imperative. 


INVERSION  OF  THE  UTERUS 


345 


The  peritoneum  is  opened  before  and  behind  the  constricting  ring; 
a  series  of  ligatures  is  then  passed  from  below  upward  on  one  side  and 
then  the  other,  cutting  close  to  the  uterus. 

It  may  be  possible  to  close  the  peritoneum  with  a  running  catgut 
suture,  after  drawing  the  broad  ligaments  down  on  either  side  and 
transfixing  them  in  the  vault  of  the  vagina. 

The  vagina  is  packed  with  iodoform  gauze  after  insuring  perfect 
control  of  all  bleeding  points. 


Fig.  236 


Fig.  237 


Vaginal  amputation  of  the  uterus. 
The  fundus  is  amputated  and  the  sutures  in  The  sutures  in  the  cervical  stump  are  tied, 

the  cervical  stump  are  in  place. 

Prognosis. — In  acute  inversion  death  may  result  from  hemorrhage, 
shock,  or  sepsis.  When  the  inversion  is  reduced  early  the  outlook  is 
favorable,  but  when  reduced  late  there  is  little  chance  of  subsequent 
childbearing  because  of  the  altered  mucosa  of  the  uterus  and  tubes. 

Anteversion. — No  sharp  distinction  can  be  drawn  between  a  physio- 
logical and  a  pathological  anteversion  of  the  uterus.  Within  perfectly 
normal  limits  the  long  axis  of  the  uterus  is  turned  forward  upon  an 
imaginary  transverse  axis.  A  permanent  exaggeration  of  this  condition 
may  be  regarded  as  pathological. 

Etiology. — ^An  exaggerated  temporary  and  physiological  anteversion 
is  found  when  the  rectum  is  distended  and  the  bladder  empty,  and 
also  in  the  early  months  of  pregnancy. 


346 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


Chronic  metritis  is  the  most  common  cause  of  acquired  pathological 
anteversion.  The  increased  weight  of  the  uterus  causes  the  body  to 
fall  forward,  the  cervix  to  turn  backward. 

Contraction  of  the  uterosacral  ligaments  from  a  retro-uterine  cellulitis 
will  draw  the  cervix  backward  and  tilt  the  body  forward.  Here  retro- 
position  is  commonly  associated  with  anteversion. 

More  rarely  adhesions  bind  the  anterior  surface  of  the  uterus  to 
the  bladder  or  abdominal  wall. 

Any  swelling  behind  the  uterus  may  exert  pressure  upon  the  uterus 
in  a  manner  that  will  produce  an  anteversion. 

A  mural  fibroid  located  in  the  anterior  wall  of  the  uterus  may  cause 
the  uterus  to  revolve  forward  by  increasing  the  weight  of  the  body. 

Fig.  238 


Anteversion  of  the  uterus.    The  cervix  points  backward  to  the  sacrum,  the  body  forward  upon  the 
bladder  and  anterior  vaginal  wall.     The  long  axis  of  the  uterus  is  straight. 


Diagnosis.^ — The  diagnosis  is  made  by  a  conjoined  examination.  The 
cervix  points  backward,  or  backward  and  upward,  and  the  body  is  pal- 
pated through  the  anterior  wall  of  the  vagina,  lying  well  upon  the 
bladder  and  behind  the  symphysis.  So  extreme  may  the  version  be 
that  the  body  may  press  down  upon  the  anterior  vault  of  the  vagina, 
forming  a  rounded  swelling  not  unlike  a  cystocele  in  appearance.  In 
such  a  case  the  external  os  will  be  difficult  to  touch  with  the  examinino- 
finger. 


ANTEFLEXION  OF   THE   UTERUS  347 

When  for  any  reason  the  position  of  the  uterus  cannot  be  located  by 
a  conjoined  examination,  the  sound  will  determine  the  direction  of 
the  uterine  canal. 

There  are  no  characteristic  symptoms.  Frequent  urination  is  the 
most  constant  complaint.  When  other  symptoms  exist  they  are 
usually  caused  by  complications  rather  than  by  simple  displacement. 

After  locating  the  uterus  in  anteversion,  the  next  step  is  to  determine 
the  cause  of  the  displacement  (Fig.  238). 

Treatment. — In  uncomplicated  anteversion  of  the  uterus  no  treatment 
is  called  for.  When  complicating  lesions  are  found,  such  as  are  classed 
above  as  causal  factors,  they  should  be  given  due  consideration  and 
not  infrequently  call  for  operative  interference. 

Anteflexion. — As  with  anteversion  so  with  anteflexion  of  the  uterus, 
it  is  not  possible  to  draw  a  line  between  the  normal  and  the  abnormal 
positions.  In  anteflexion  the  uterus  is  bent  forward  upon  its  long 
axis. 

Symptoms.— The  subjective  signs  of  anteflexion  of  the  uterus  are 
frequent  urination,  dysmenorrhea,  and  sterility,  though  these  are  by 
no  means  constant.  It  is  not  likely,  as  is  generally  believed,  that 
dysmenorrhea  is  due  to  obstruction  to  the  outflow  of  the  menstrual 
blood.  The  angle  of  flexion  can  scarcely  be  so  acute  as  to  interfere 
with  the  outflow  of  blood.  The  explanation  probably  lies  in  the  accom- 
panying inflammatory  lesions  in  and  about  the  uterus  and  possibly 
also  in  spasmodic  contractions  of  the  internal  os.  Sterility  can  prob- 
ably be  accounted  for  by  the  accompanying  inflammatory  lesions 
rather  than  by  the  flexion.  When  the  cervix  points  well  forward  the 
spermatozoa  cannot  so  readily  gain  access  to  the  cervix  as  when  it  is 
directed  toward  the  posterior  wall  of  the  vagina. 

Diagnosis. — In  an  abdominovaginal  examination,  the  body  of  the 
uterus  should  be  engaged  between  the  two  hands  and  the  angle  of 
flexion  felt  by  the  finger  within  the  vagina.  When  the  anteflexed  uterus 
lies  in  retroposition,  the  flexion  may  be  best  found  by  the  finger  high 
in  the  rectum,  feeling  the  angle  upon  the  posterior  surface  of  the  uterus 
as  the  body  bends  forward  upon  the  cervix.  This  examination  will  be 
materially  facilitated  by  an  anesthetic.  The  sound  will  be  of  special 
service  when  it  is  otherwise  impossible  to  outline  the  uterus  because  of 
tumors  and  inflammatory  exudates  encroaching  upon  it.  The  size, 
shape,  and  consistency  of  the  uterus  will  usually  serve  to  distinguish 
it  from  all  such  swellings. 

Having  determined  the  position  of  the  uterus,  and  before  any  treat- 
ment is  proposed,  it  is  essential  to  clearly  define  the  cause  of  the  dis- 
placement. Is  the  uterus  fixed  or  free  and  movable?  If  free  and 
movable,  the  fault  may  be  a  h33)oplasia  of  the  uterine  wall  at  the  point 
of  flexion,  and  is,  in  all  probability,  a  congenital  defect.  Here  the 
uterus  is  often  found  to  be  undersized  (h^-poplasia) .  If  the  uterus 
is  restricted  in  its  movements,  the  cause  may  be  a  congenital  or 
an  acquired  shortening  of  the  uterosacral  ligaments;  new-formations 
or  exudates  lying  behind  the   body   of  the  uterus   and  crowding  it 


348 


MALPOSITIONS  OF   THE  GENITAL  ORGANS 


forward;  or  less  frequently,  the  explanation  may  be  found  in  an  increase 
in  the  weight  of  the  body  of  the  uterus. 

An  intramural  fibroid  lying  in  the  anterior  wall  of  the  uterus  may 
form  an  angle  with  the  cervix,  which  to  the  examining  finger  resembles 
an  anteflexion.  The  form  and  consistency  of  the  tumor,  together 
with  the  passage  of  the  sound,  will  locate  the  uterus  apart  froni  the 
tumor  (Fig.  239).    Anteversion  and  anteflexion  are  frequently  combined. 

Fig.  239 


Uterine  fibroid  resembling  anteflexion  of  the  uterus.  The  uterus  is  bent  forward  upon  its  long 
axis.  There  is  little  alteration  from  the  normal.  A  subperitoneal  fibroid  on  the  anterior  wall  forms 
a  sharp  angle,  resembling  an  anteflexed  uterus. 


Treatment. — An  uncomplicated  pathological  anteflexion  of  the  uterus 
may  demand  operative  interference,  but  never  topical  applications. 
The  author  condemns  the  pernicious  practice  of  passing  sounds  into 
the  uterus,  of  introducing  stem  pessaries,  and  the  so-styled  anteflexion 
pessaries.  They  can  serve  no  good  purpose  and  are  capable  of  much 
harm. 

In  anteflexion,  as  in  all  displacements  of  the  uterus,  the  treatment 
should  be  primarily  directed,  so  far  as  possible,  toward  the  removal 
of  the  exciting  cause;  hence  it  follows  that  the  treatment,  if  it  is  to  be 
effective,  must  vary  with  existing  complications.  Tumors  lying  behind 
the  uterus  are  to  be  removed;  inflammatory  lesions  demand  topical 
and  operative  treatment;  and  a  chronic  inflammation  or  subinvolu- 


ANTEFLEXION  OF  THE   UTERUS 


849 


tion  of  the  uterus  must  be  treated  along  conservative  lines  if  relief  is 
to  be  obtained. 

Dilatation  of  the  Cervix. — There  is  but  one  method  of  procedure  that 
is  generally  adopted  for  the  correction  of  a  pathological  anteflexion. 
This  consists  in  forcibly  dilating  the  cervical  canal  under  anes- 
thesia. For  this  purpose  the  author  prefers  Hegar's  graduated  bougies, 
and  to  consume  ten  to  fifteen  minutes  in  the  operation.  By  this 
deliberate  process  a  No.  14  bougie  should  be  passed  without  tearing 
the  cervix.  Traction  made  upon  the  cervix  by  a  vulsellum  forceps 
will  aid  in  straightening  out  the  cervical  canal.  To  prevent  the  acci- 
dental puncture  of  the  uterus  the  body  is  first  located  by  a  bimanual 
examination,  and  the  direction  of  the  cervical  canal  and  uterine  cavity 


Fig.  240 


Pl.i.u.  — 


V.  " 


Va.p. 


/ 


Prolapse  of  the  anterior  and  posterior  vaginal  walla.  Partial  prolapse  of  the  uterus.  Uterus  ante- 
flexed  and  prolapsus  partially  corrected  by  distended  bladder  and  rectum.  Pl.i.u.,  uterine  ligament; 
U,  urethra;  R,  rectum;  Va.p.,  vaginal  fornix.     (Tandler  and  Halban.) 


further  determined  by  the  passage  of  a  uterine  sound.  The  author  has 
found  the  operation  facilitated  by  dipping  the  ends  of  the  bougies  in 
sterile  glycerin.  To  prevent  the  bougies  from  suddenly  slipping  too 
far  into  the  uterus  and  possibly  perforating  it,  the  forefinger  should 
be  placed  about  one  inch  from  the  end  of  the  bougie  as  it  is  being  forced 
through  the  cervical  canal.    (See  Fig.  53.) 


350 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


_  The  author  has  frequently  resorted  to  the  use  of  an  instrument  of 
divulsion   (Ellinger,  Goodell)  to  supplement  the  bougies  when  there 


Fig.  241 


Fig.  242 


Dudley  operation  for  anteflexion. 


are  great  difficulties  encountered.  In  no  case  has  he  found  it  necessary 
to  incise  the  internal  os  with  a  bistoury  passed  into  the  cervical  canal. 
Time  and  patience  will  usually  overcome  these  obstacles. 


ANTEFLEXION  OF  THE   UTERUS 


351 


After  thoroughly  dilating  the  cervix,  the  uterus  is  curetted  and 
swabbed  with  pure  formalin  or  equal  parts  of  the  tincture  of  iodine 
and  pure  carbolic  acid.  Some  authors  advise  the  packing  of  the  uterus 
with  antiseptic  gauze;  others  prefer  to  introduce  a  glass  stem  pessary. 
These  procedures  the  author  has  never  adopted.  The  patient  should 
be  confined  to  bed  for  a  week  after  the  operation. 

Fig.  244 


Retroposition  and  retroversion  of  the  uterus.  The  distended  bladder  crowds  the  uterus  backward 
into  retroversion  and  retroposition.  When  the  bladder  is  empty  the  uterus  will  fall  forward  into 
anteversion  and  anteposition. 


Dudley's  Operation. — The  Dudley  operation  for  anteflexion  has  been 
received  with  favor  as  a  method  of  treatment  for  exaggerated  cases. 
The  following  is  Dudley's  description  of  the  operation: 

Step  1.  The  cervix  is  dilated  to  a  moderate  degree  and  the  uterus 
curetted. 

Step  2. — The  anterior  lip  of  the  cervix  is  grasped  with  a  vulsellum 
forceps  and  traction  made  downward  and  forward.  A  median  incision 
is  made  with  scissors  through  the  posterior  wall  of  the  cervix  to  a 
point  beyond  the  uterovaginal  attachment  and  nearly  to  the  utero- 
peritoneal fold  in  the  pouch  of  Douglas    (Fig.  241). 

Step  S. — An  assistant  grasps  the  divided  surfaces  with  tenacula  and 
separates  them  widely,  while  the  operator  cuts  out  a  small  angle  on 


352 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


either  side  as  shown  in  Fig.  242.  The  cut  surfaces  are  then  folded  upon 
themselves  by  a  single  silkworm-gut  suture  as  shown  in  Fig.  243.  Addi- 
tional interrupted  sutures  are  passed  for  further  security.  In  this 
manner  each  cut  surface  is  folded  upon  itself  from  before  backward. 
This  directs  the  external  os  backward  to  the  angle  of  the  incision  and 
turns  the  cervix  to  the  hollow  of  the  sacrum. 

Retroversioflexion. — In  retroversion  the  long  axis  of  the  uterus 
revolves  backward  upon  an  imaginary  transverse  axis.  Such  a  posi- 
tion is  physiological  when  the  bladder  is  full  and  the  rectum  empty, 
the  patient  lying  on  her  back. 


Retroposition  and  retroversion  of  the  uterus,  with  fixation.  Peritoneal  adhesions  bind  the  posterior 
surface  of  the  uterus  to  the  sacrum  and  rectum,  holding  the  uterus  firmly  in  retroversion  and  retro- 
position. 


In  retroflexion  the  uterus  is  bent  backward  upon  its  long  axis.  There 
is  no  physiological  retroflexion  of  the  uterus. 

The  two  positions,  retroversion  and  retroflexion,  are  caused  by  the 
same  factors,  and  are  commonly  combined ;  retroflexion  following  retro- 
version. Because  of  their  intimate  association  they  will  be  discussed 
together.  In  virgins  and  in  chronic  metritis  the  uterus  is  seldom 
flexed,  but  remains  in  retroversion  rather  than  in  retroversioflexion 
(Fig.  245). 


RETROVERSIOFLEXION  OF  THE   UTERUS 


353 


Etiology. — Schultze  gives  five  causes  for  retro versioflexion,  namely: 

1.  Failure  in  development. 

2.  Fixation  of  the  portio  vaginalis  on  the  anterior  pelvic  wall. 

3.  Unilateral  posterior  fixation  of  the  cervix. 

4.  Shortening  of  the  posterior  or  lengthening  of  the  anterior 

uterine  wall. 

5.  Relaxation  of  the  supporting  uterine  ligaments  and  muscles. 

Fig.  246 


Retroversioflexion  of  the  uterus,  with  adhesions.     The  body  is  adherent  in  the  oul-de-sao.     The 
long  axis  of  the  uterus  is  bent  backward  and  the  cervix  is  directed  downward. 

1.  Among  the  developmental  failures  contributing  to  retroversio- 
flexion may  be  mentioned  the  proportionately  long  cervix  and  short 
vagina.  In  the  presence  of  such  a  condition,  an  increase  in  the 
abdominal  tension  or  a  sudden  fall  would  be  sufficient  cause  for  a 
retroversioflexion. 

2.  Fixation  of  the  portio  vaginalis  upon  the  anterior  pelvic  wall  may 
be  the  result  of  cicatricial  contraction  of  the  anterior  wall  of  the  vagina. 
Hence  it  is  that  retroversioflexion  is  frequently  found  in  large  vesico- 
vaginal fistulse  and  in  stenosis  of  the  vagina. 

3.  Unilateral  posterior  fixation  of  the  cervix  occurs  in  about  6  per 
cent,  of  all  cases  of  retroversioflexion  (Schultze).  The  cause  is  retro- 
uterine cellulitis  or  peritonitis,  more  often  confined  to  one  sacro-uterine 
ligament. 

23 


354 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


4.  Shortening  of  the  posterior  wall  or  lengthening  of  the  anterior 
wall  of  the  uterus  is  a  rare  finding. 

5.  Relaxation  of  the  supporting  uterine  ligaments  and  muscles  is 
by  far  the  most  frequent  cause  of  retroversioflexion.  When  these 
supports  are  weakened,  the  long  axis  of  the  uterus  first  revolves  back- 
ward upon  an  imaginary  transverse  axis  (retroversion),  and  later, 
through  the  force  of  intra-abdominal  pressure,  the  long  axis  of  the 
uterus  is  bent  upon  itself  (retroflexion).  The  stretching  and  tearing 
of   childbirth  largely   account   for  the   relaxation   of  the   supporting 


Fig.  247 


Incarcerated  subperitoneal  fibroid  on  the  posterior  wall  of  the  uterus.     The  fibroid  may  be  con- 
founded ■with  the  bodj'  of  the  uterus.     The  uterus  lies  in  retroversioflexion. 


uterine  ligaments  and  muscles.  Retroversioflexion  due  to  violent 
exertion  or  to  a  fall  is  difficult  to  establish,  though  not  impossible.  The 
cause  of  retrodisplacements  of  the  uterus  in  the  nullipara  is  difficult 
of  explanation  in  the  absence  of  swellings  crowding  the  uterus  backward 
or  adhesions  pulling  it  backward.  Tight-lacing  and  habitual  overfilling 
of  the  bladder  will  account  for  a  limited  number  of  these  cases.  Not  a 
few  are  congenital,  as  is  shown  by  anatomical  dissections  of  infants. 
Salin  found  as  many  nulliparae  as  multiparse  with  retroversioflexion. 
He  estimates  the  frequency  of  this  displacement  in  all  cases  at  18  per 
cent. 


RETROVERSIOFLEXIOX  OF  THE   UTERUS 


600 


Heredity  probably  plays  no  role,  though  mother  and  daughters  are 
often  similarly  affected. 

During  the  puerperium,  when  the  uterus  is  large  and  soft,  the  liga- 
ments relaxed,  and  the  patient  lying  on  her  back,  all  the  conditions 
favoring  retroversion  are  present.  This  retroversion  may  go  on  to  the 
development  of  a  retroflexion  through  the  influence  of  intra-abdominal 
pressure.  Rising  too  early  from  childbed  favors  malpositions,  as  well 
as  does  lying  too  long  in  the  dorsal  position.  It  is  for  the  purpose  of 
avoiding  such  malpositions  that  the  patient  is  instructed  to  lie  in  bed 
until  the  uterus  and  ligaments  are  well  contracted  and  retracted.  It 
is  obvious  that  the  patient  should  not  lie  constantly  in  the  dorsal  posi- 
tion, but  should  from  time  to  time  assume  the  knee-chest  position,  or 
at  least  lie  upon  the  side  or  face. 

Fig.  248 


O.Urec. — ^ 


Retroversion  of  uterus. 


Rectocele 

Begiiming  cystocele  and  rectocele. 
(Tandler  and  Halban.) 


O.Uret.,  ureteral  opening. 


As  to  the  frequency  of  retrodeviations  of  the  uterus,  the  statistics 
of  AYinckel,  Lohlen,  and  Sanger  show  an  average  of  17.74  per  cent,  of 
all  gynecological  cases  (Reed). 

Anatomical  Diagnosis. — When  the  cervix  is  crowded  forward  the 
anterior  vaginal  wall  is  relaxed,  while  the  posterior  wall  is  taut. 
In   retroversion  the  cervix  points  forward  or  forward  and  upward, 


356 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


sometimes  lying  above  the  level  of  the  symphysis.  In  retroflexion  the 
cervix  is  directed  downward  and  backward.  When  the  body  of  the 
uterus  lies  in  the  hollow  of  the  sacrum,  the  cervix  must  necessarily  lie 
well  forward  to  the  symphysis.  If,  as  is  often  found,  retroversioflexion 
is  associated  with  descensus  uteri,  the  cervix  may  be  elongated.  If  a 
bilateral  laceration  of  the  cervix  is  present,  the  vaginal  walls  will  draw 
the  lips  of  the  cervix  wide  apart,  exposing  the  mucous  membrane  of 
the  cervical  canal. 

In  retroversion  the  body  of  the  uterus  approaches  the  promontory, 
and  may  be  found  low  in  the  pouch  of  Douglas.  There  is  no  angle 
of  flexion  between  the  body  and  cervix.  The  cervix  and  body  lie  in 
a  straight  line.  In  retroflexion  the  body  may  form  an  acute  angle 
with  the  cervix.  Often  the  uterus  in  retroversioflexion  inclines  to  the 
left  or  right,  and  in  extreme  cases  is  almost  invariably  more  or  less 
prolapsed. 

Fio,   249 


Retroversion  of  the  uterus.    Prolapse  of  the  entire  bladder.    Deepening  of  the  vesico-uterine  pouch. 
E.U.V.,  vesico-uterine  pouch.     (Tandler  and  Halban.) 

Edema  and  passive  congestion,  leading  to  hyperplasia  of  the  endome- 
trium and  myometrium,  are  the  almost  inevitable  results  of  the  dis- 
placement. We,  therefore,  find  endometritis  and  metritis  associated 
with  long-standing  retroversioflexion.  Frequently  diffuse  peritoneal 
adhesions  bind  the  uterus,  tubes,  ovaries,  and  bowel  together.  The 
tubes  and  ovaries  lie  at  a  low  level  and  suffer  congestion  and  hyper- 


RETROVERSIOFLEXION  OF  THE  UTERUS  357 

plastic  changes,  leading  to  catarrhal  salpingitis,  chronic  ovaritis,  and 
cystic  degeneration  of  the  ovaries. 

The  bladder  may  be  directly  pressed  upon  by  the  cervix,  causing 
frequent  urination.  In  the  retroflexed,  gravid  uterus  there  may  be 
retention  of  urine. 

The  rectum  is  compressed,  and  may  be  obstructed  by  the  body  of 
the  uterus. 

Clinical  Diagnosis. — The  great  number  of  cases  of  retro versioflexion 
in  which  no  symptoms  are  present  speak  for  the  unreliability  of 
subjective  signs.  Wormser  asserts  that  uncomplicated  cases  of  retro- 
flexion in  healthy  women  produce  no  symptoms.  When  disturbances 
exist,  some  local  complication  must  be  present,  or  there  is  a  deranged 
nervous  system.  E.  Schroeder  reports  411  cases  examined,  in  which 
188  (28.7  per  cent.)  had  retroversioflexion  of  the  uterus,  and  of  this 
number  25  per  cent,  were  free  from  symptoms.  He  reasons  that 
uncomplicated  retrodisplacements  of  the  uterus  cause  no  symptoms; 
that  those  so  frequently  ascribed  to  such  displacements  are  due  to 
complicating  lesions.  Yet  we  often  find  extensive  adhesions  fixing  the 
uterus  in  malpositions  without  causing  either  local  or  general  disturb- 
ances. On  the  other  hand,  the  disappearance  of  local  disturbances 
immediately  upon  the  correction  of  a  non-complicated  displacement 
cannot  be  wholly  explained  on  the  ground  of  suggestive  treatment. 

Menstrual  Irregularities. — Menstrual  irregularities  are  common,  and 
usually  take  the  form  of  an  increase  in  the  menstrual  flow.  This  is 
explained  by  the  passive  congestion  of  the  uterus.  Extreme  anemia 
may  result  from  the  loss  of  menstrual  blood.  The  menopause  may 
be  delayed  because  of  the  passive  congestion.  During  pregnancy 
and  the  period  of  lactation,  occasional  hemorrhages  can  be  similarly 
accounted  for. 

Abortion. — The  habit  of  abortion  is  in  many  instances  explained  by 
the  uterine  congestion. 

Leucorrhea. — Leucorrhea,  in  the  form  of  a  hypersecretion  of  the 
glands  of  the  uterus,  is  almost  invariably  present,  and  is  caused  by 
passive  congestion  of  the  uterus. 

The  congested  uterus  is  a  favorable  nidus  for  microorganisms,  and 
so  it  happens  that  the  glandular  secretion  is  often  mixed  with  pus 
and  microorganisms. 

Dysmenorrhea. — Dysmenorrhea  of  the  so-called  congestive  type  is 
seldom  absent.  It  is  not  probable  that  the  menstrual  flow  is  obstructed 
at  the  point  of  flexion.  The  occurrence  of  pain  may  be  explained 
by  the  addition  of  the  menstrual  congestion  to  the  already  engorged 
uterus. 

Sterility. — Sterility  is  a  not  uncommon  result  of  retroversioflexion  of 
the  uterus.  The  incapacity  for  childbearing  should  be  credited  not 
so  much,  if  at  all,  to  the  flexion  of  the  uterus,  as  to  the  inaccessibility 
of  the  cervix  to  spermatozoa  when  it  is  crowded  forward  and  upward, 
to  changes  in  the  endometrium,  and  to  complicating  lesions  in  the 
adnexse  and  perimetrium. 


358  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

Disturbances  of  Bladder  and  Rectum. — Disturbances  of  the  functions 
of  the  bladder  and  rectum  are  accounted  for  by  direct  pressure. 

Pain. — Pain  in  the  pelvis  referred  to  the  groin,  thighs,  and  back  is 
the  most  constant  of  the  subjective  signs,  but  cannot  be  regarded 
as  of  great  importance  from  a  diagnostic  standpoint,  because  pain 
is  not  an  invariable  symptom  and  does  not  differ  from  that  caused 
by  other  lesions  of  the  pelvic  viscera.  Backache  is  a  common  com- 
plaint, and  is  referred  to  the  coccyx  (coccygodynia),  to  the  lumbar 
region,  or  to  the  area  between  the  scapulae;  rarely  to  the  cervical  region. 
The  absence  of  pain  in  many  extreme  retrodisplacements  of  the  uterus 
suggests  a  doubt  that  the  displaced  uterus  per  se  is  the  cause  of  the 
pain;  Certainly  the  accompanying  lesions,  such  as  ovaritis,  salpingitis, 
and  perimetritis,  account  in  large  measure  for  the  pain.  Pressure 
upon  the  sacral  plexus  of  nerves  is  often  the  explanation  for  the  pain 
referred  to  the  thighs,  and  since  the  uterus  is  rarely  found  in  the 
median  line,  these  referred  pains  in  the  lower  extremities  are  for  the 
most  part  unilateral. 

Reflex  Symptoms. — Reflex  symptoms,  such  as  headache,  neuralgia, 
dyspepsia,  hysteria,  and  neurasthenia,  are  often  attributed  to  the 
displacement,  but  it  seems  impossible  to  demonstrate  such  to  be  a 
fact  with  any  degree  of  positiveness. 

It  is  clear  that  a  diagnosis  cannot  be  based  upon  the  subjective 
signs.  Too  many  cases  exist  in  their  absence,  and  the  complaints  of 
the  patient  are  those  found  in  almost  any  of  the  lesions  of  the  pelvis. 
A  physical  examination  is  therefore  required  to  establish  a  diagnosis. 
A  diagnosis  includes  not  only  the  location  of  the  uterus,  but  also  the 
condition  of  the  adnexee  and  neighboring  structures.  Here,  as  in  the 
diagnosis  of  all  displacements  of  the  uterus,  it  is  first  necessary  to 
locate  the  uterus,  and,  second,  to  determine  the  underlying  cause  of 
the  displacement  and  the  existence  of  complicating  lesions  within  the 
pelvis  and  abdominal  cavity. 

In  making  a  bimanual  examination  the  position  of  the  vaginal  portion 
of  the  cervix  may  be  an  indication  of  the  position  of  the  uterine  body. 
For  example,  if  the  cervix  lies  in  its  normal  position,  pointing  dowuM^ard 
and  backward  toward  the  second  sacral  vertebrae,  the  body  must  lie 
in  the  normal  position  or  retroflexed;  it  would  be  impossible  for  a  retro- 
version to  exist  with  the  cervix  pointing  downward  and  backward. 
If  the  cervix  lies  in  front  of  its  normal  position  and  points  directly 
downward,  one  of  two  positions  is  present,  a  retroflexion  or  an  ante- 
position.  It  is  sometimes  possible  to  recognize  a  retroflexion  in  a 
simple  vaginal  palpation  by  feeling  the  angle  of  flexion  through  the 
posterior  fornix.  When  conditions  are  not  favorable,  a  positive  diag- 
nosis of  the  position  of  the  uterus  can  only  be  made  by  a  conjoined 
examination  under  anesthesia. 

A  recto-abdominal  or  rectovagino-abdominal  examination  affords 
better  means  of  palpating  the  uterus  when  lying  far  back  against  the 
rectum. 


RET ROVERSIO FLEXION  OF  THE   UTERUS 


359 


The  use  of  the  sound  should  be  restricted,  but  it  is  occasionally 
called  into  service  when  a  bimanual  examination  will  not  suttice 

Is  tl^  uterus  fixed  or  movable?  First  of  all  we  must  have  clearly 
in  mind  what  constitutes  normal  mobility  of  the  uterus.  It  is  not 
enough  that  the  uterus  should  permit  the  usual  excursions  when  man- 
ipulated, but  it  must  return  to  its  normal  position  when  pressed  out 
of  place.    Failing  to  do  so  constitutes  a  pathological  condition. 

Fig.  250 


0.  uret. 
Retroversion  and  descensus  uteri.     Beginning  cystocele.     0.  uret,  ureteral  opening. 

(Leipmann.) 

The  fixitv  of  the  uterus  is  determined  by  the  effort  to  replace  it. 
Sensitiveness  and  thickness  of  the  abdominal  wall  may  render  an 

anesthetic  necessary.  •  n     •        •     u^;^fl^r 

The  technic  of  replacing  a  uterus  m  retroversioflexion  ib   briefly 

outlined  as  follows:  .     .  v     •    ^i,    T+i.^+^T.-,Ar 

The  bladder  and  rectum  are  empty.  The  patient  lies  m  the  lithotomy 
position.  One,  and  where  possible  without  causing  pam,  two  fingers  are 
inserted  into  the  posterior  vaginal  fornix,  and  moderate  steady  pressiire 
is  made  upon  the  uterine  body  in  an  upward  and  forward  direction,    ifie 


360  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

hand  over  the  abdomen  presses  steadily  in  the  effort  to  pass  over  and 
behind  the  fundus,  as  it  is  forced  upward  and  forward  by  the  fingers 
in  the  vagina.  Sometimes  the  body  will  rotate  forward  by  the  finger 
pressing  backward  upon  the  cervix.  With  the  middle  finger  in  the 
rectum,  it  is  possible  to  exercise  more  direct  pressure  upon  the  body 
of  the  uterus  in  extreme  retroflexion.  Traction  upon  the  cervix  by  a 
tenaculum  will  bring  the  uterus  more  within  reach  of  the  fingers  in 
the  vagina  and  rectum.  An  anesthetic  is  usually  advisable.  Formerly, 
in  reposition  of  the  uterus,  a  sound  was  advised,  but  the  danger  of 
perforations  is  too  great  to  justify  its  general  use.  Certain  it  is  that 
the  sound  should  not  be  used  when  the  uterus  is  fixed.  In  replacing 
the  uterus  force  must  not  be  used  for  fear  of  tearing  existing  adhesions, 
causing  hemorrhage  and  injuring  adherent  viscera. 

Having  determined  the  position  of  the  uterus  and  the  fact  that 
it  is  not  replaceable,  it  next  becomes  necessary  to  determine  the  cause 
of  the  inhibition.  As  possible  causes  may  be  mentioned  adhesions  and 
pelvic  exudates,  inflammatory  contractions  of  the  ligaments,  and 
pelvic  tumors.  Peritonitic  adhesions  (peritonitis)  for  the  most  part 
arise  from  extension  of  infection  through  the  tubes,  and  are  most  often 
found  about  the  tubes  and  ovaries.  Since  infected  tubes  commonly 
lie  in  the  cul-de-sac  of  Douglas,  the  surrounding  adhesions  may  bind 
the  uterus  to  the  rectum  in  retroversion  or  retroflexion.  Peritoneal 
adhesions  are  recognized  by  their  location  on  surfaces  covered  with 
peritoneum  and  by  the  ease  with  which  they  may  be  broken  up  as 
compared  with  parametritic  adhesions. 

Parametritic  adhesions  correspond  in  location  to  the  cellular  tissue 
of  the  pelvis,  which  is  found  between  the  layers  of  the  broad  ligament, 
underneath  the  pouch  of  Douglas,  and  to  a  limited  extent  in  front  of 
the  uterus  beneath  the  vesico-uterine  fold  of  peritoneum. 

Retro versioflexion  may  be  brought  about  by  adhesions  in  the  cellular 
tissue  of  the  vesico-uterine  space  drawing  the  cervix  forward  and 
rotating  the  body  backward — this,  however,  is  quite  unusual. 

Retro-uterine  parametritis,  when  involving  only  the  supravaginal 
portion  of  the  cervix,  tends  to  produce  an  anteversion  by  drawing 
the  cervix  backward  and  rotating  the  body  forward.  In  extreme 
cases  the  uterorectal  fold  of  peritoneum  may  be  crowded  upward  and 
permit  the  parametritic  adhesions  to  adhere  high  up  upon  the  posterior 
surface  of  the  uterus,  and,  by  traction  upon  the  body,  a  retroversion  is 
caused.  Parametritic  adhesions  are  thicker  and  firmer  than  they  are 
in  parametritis.  They  are  found  on  a  lower  level,  are  more  accessible 
through  the  vagina,  and  are  located  where  the  cellular  tissue  of  the 
pelvis  is  found. 

Pregnancy  in  a  retroflexed  uterus  may  prove  a  serious  condition. 
No  special  difficulty  may  be  experienced  in  the  first  two  months,  but  in 
the  third  and  fourth  months  the  uterus,  no  longer  able  to  accommodate 
itself  to  the  small  pelvis,  is  prevented  from  rising  into  the  abdominal 
cavity.  As  a  result  pregnancy  will  be  interrupted,  or  pressure  symp- 
toms will  become  increasingly  severe  and  demand  correction.     On 


RETROVERSIOFLEXION  OF  THE   UTERUS 


361 


bimanual  examination  the  large,  soft,  and  elastic  uterus  may  be  found 
to  bulge  into  the  posterior  vaginal  fornix  even  to  the  introitus.  The 
cervix  is  forced  high  behind  the  symphysis,  and  is  directed  forward 
or  forward  and  downward.  The  soft  cervix  and  softer  lower  uterine 
segment  may  be  felt  to  connect  at  an  angle  with  the  large,  rounded, 
soft,  and  elastic  body  of  the  uterus.  Because  of  the  great  softening 
the  uterine  body  may  appear  detached  from  the  cervix,  and  in  case 
the  cervix  is  hypertrophied,  it  may  be  mistaken  for  the  entire  uterus 
and  the  body  may  be  thought  to  be  a  newgrowth. 


Fig.  251 
25.  S6.     27. 


Myomatoua  uterus.  Medial  section  of  pelvis.  1,  subserous  fibroid;  2,  cavity  of  uterus;  3,  inter- 
stitial fibroid;  4,  interstitial  fibroid;  5,  submucous  fibroid;  6,  promontory  of  sacrum;  7,  interstitial 
fibroid;  8,  rectum;  9,  posterior  vaginal  fornix;  10,  coccyx;  11,  cul-de-sac  of  Douglas;  12,  vesico-uterine 
fold  or  peritoneum;  13,  rectum;  14,  sound  in  rectum;  15,  levator  ani  muscle;  16,  internal  sphincter 
ani;  17,  perineum;  18,  vagina;  19,  urinary  bladder;  20,  urethra;  21,  labium  majus;  22,  external  orifice 
of  urethra;  23,  chtoris;  24,  symphysis  pubis;  25,  cavum  Retzii;  26,  pjTaniidal  muscle;  27,  rectus 
abdominus.     (Leipmann.) 


Differential  Diagnosis. — From,  Retroposition. — Retroversioflexion  is 
most  often  confounded  with  retroposition.  In  the  latter  the  cervix 
lies  in  the  posterior  segment  of  the  pelvis,  while  in  retroversioflexion 
it  lies  anterior  to  the  normal  position.  In  both  conditions  the  body 
of  the  uterus  lies  far  back  in  the  pelvis,  but  in  the  latter  the  long  axis 
of  the  uterus  is  no  longer  in  the  normal  line  of  direction. 


362  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

From  Anteflexion. — Anteflexion  may  be  mistaken  for  retroversion. 
The  cervix  points  in  the  same  direction — forward  and  downward — 
and  the  body  may  be  small,  and  therefore  overlooked  or  mistaken  for 
the  supravaginal  portion  of  the  cervix.  If  on  bimanual  examination 
the  body  of  the  uterus  cannot  be  located  a  sound  may  be  passed. 

From  a  Fibroid. — A  retro-uterine  subperitoneal  or  interstitial  fibroid 
may  form  an  angle  with  the  cervix  that  can  be  mistaken  for  the  body 
flexed  upon  the  cervix.  The  body  of  the  uterus  is  recognized  by  its 
size,  form,  consistency,  and  direct  relation  to  the  cervix.  Such  a  fibroid 
should  present  a  circumscribed  area  of  firmer  consistency  and  produce 
an  irregularity  in  the  uterus.  When  the  bimanual  examination  will 
not  suffice  for  a  diagnosis,  the  uterine  sound  may  be  used. 

Swellings  of  the  tubes  and  ovaries  lying  behind  the  uterus,  retro- 
uterine hematoma  and  hematocele,  and  parametritic  exudates  are 
all  to  be  differentiated  from  retroversioflexion  by  a  consideration  of 
the  clinical  history,  and  by  finding  a  mass  behind  the  uterus  that  differs 
in  size,  form,  and  consistency  from  the  uterus,  and  which,  by  the  use 
of  the  sound,  is  found  to  be  separate  from  the  uterus.  For  further 
discussion,  see  respective  chapters  on  these  subjects. 

Treatment. — Do  all  .cases  of  retroversioflexion  of  the  uterus  demand 
correction?  In  answer  to  this  question,  the  author  would  say  that  in 
uncomplicated  cases  in  which  there  are  no  disturbances  referable  to 
the  displacement  no  operative  interference  should  be  advised.  In 
view,  however,  of  the  possible  development  of  tissue  changes  within 
the  uterus  and  its  adnexse,  which  in  time  will  almost  surely  give  rise 
to  functional  disturbances,  it  w^ould  be  well  to  correct  the  displacement 
by  manual  reduction  and  the  application  of  a  pessary.  Such  treatment 
can  do  no  harm  and  may  be  the  means  of  preventing  future  disorders 
which  are  so  commonly  the  result  of  retroversioflexion  of  long  standing. 

Treatment  of  Acute  Retroversioflexion. — When  the  displacement  is 
known  to  exist  less  than  one  year,  the  treatment  may  proceed  along 
conservative  lines,  with  a  reasonable  assurance  of  success.  After  this 
time  there  is  little  hope  of  giving  permanent  relief  by  any  means  short 
of  an  operative  procedure.  The  explanation  lies  in  the  condition  of  the 
uterine  supports.  If  the  uterus  is  early  replaced  and  held  in  place, 
the  supports  which  have  been  stretched  and  displaced  may  resume 
their  normal  position  and  tonicity.  But  through  continual  over- 
stretching there  is  little  probability  of  their  ever  retracting  to  a  degree 
sufficient  to  support  the  uterus  in  its  normal  position. 

It  is  not  advisable  to  persist  for  more  than  several  months  in  the 
effort  to  restore  a  recent  displacement;  at  the  end  of  this  time,  if  not 
successful,  the  condition  must  be  regarded  as  chronic  and  not  amenable 
to  permanent  correction  by  conservative  methods.  The  treatment 
should  then  consist  of: 

Removal  of  the  Cause.^ — The  great  majority  of  recent  displacements 
follow  abortions  and  childbearing  at  term.  Not  only  are  the  ligaments 
stretched  but  the  pelvic  floor  is  commonly  stretched  and  torn.  Further- 
more, the  uterus  is  almost  invariably  subinvoluted.    In  such  an  event 


RET ROVERSIO FLEXION  OF  THE  UTERUS  363 

the  intra-abdominal  pressure  should  be  relieved  by  the  wearing  of  an 
abdominal  binder,  and  by  regulating  the  bowels  to  prevent  constipation 
with  straining  at  stool.  The  position  of  the  patient  should  be  shifted 
from  time  to  time  from  the  back  to  the  side  and  to  the  knee-chest 
position.  Injuries  to  the  cervix,  vaginal  walls,  and  pelvic  floor  should  be 
repaired.  When  there  is  retained  placental  tissue  it  should  be  removed. 
An  infected  uterus  should  not  be  curetted  but  should  be  treated  along 
rational  conservative  lines.  (See  page  439.)  If  the  uterus  is  congested 
it  should  be  depleted  by  vaginal  packs  and  hot  douches,  and  finally 
the  uterine  supports  should  be  strengthened  by  intelligently  conducted 
pelvic  massage. 

Replacement  of  the  Uterus. — This  should  be  effected  after  all 
complicating  lesions,  which  would  prevent  ready  and  lasting  replace- 
ment, have  been  removed.  This  may  be  accomplished  by  the  bimanual 
method  and  by  the  knee-chest  position. 

Bimanual  Method. — The  index  and  middle  fingers  of  the  left  hand 
are  introduced  into  the  vagina,  back  of  the  cervix,  and  are  crowded 
forward  upon  the  posterior  wall  of  the  cervix  and  body  of  the  uterus 
as  far  as  the  vaginal  wall  will  permit.  In  extreme  cases  the  vulsellum 
forceps  may  be  made  to  grasp  the  posterior  lip  of  the  cervix,  by  which 
the  assistant  may  make  traction  upon  the  cervix.  As  a  further  aid 
the  index  finger  is  introduced  into  the  vagina  and  the  middle  finger 
into  the  rectum.  By  means  of  the  two  fingers  the  fundus  is  pushed 
in  the  direction  of  the  promontory  of  the  sacrum.  This  method  is 
especially  valuable  when  the  vaginal  walls  are  unyielding. 

When  the  fundus  is  brought  to  the  level  of  the  promontory  of  the 
sacrum,  unless  the  abdominal  walls  are  thick  and  tense,  the  fundus 
may  be  grasped  by  the  fingers  of  the  right  hand,  which  depress  the 
abdominal  wall.  When  the  fundus  is  under  the  control  of  the  right 
hand  the  finger  within  the  vagina  is  shifted  to  the  anterior  lip  of  the 
cervix  and  is  made  to  push  the  cervix  backward  while  the  hand  on  the 
abdomen  draws  the  uterus  forward. 

Knee-chest  Position. — With  a  perfectly  movable  uterus,  replacement 
to  the  normal  position  is  often  possible  by  placing  the  patient  in  the 
genu-pectoral  position.  Before  assuming  this  posture,  the  waist  binding 
should  be  loosened  and  the  bladder  and  rectum  empty.  A  firm  table  or 
couch  is  preferred  and  on  it  the  patient  assumes  the  knee-chest  position. 
This  consists  in  resting  upon  the  chest  and  knees,  the  arms  extended  to 
the  sides,  and  the  side  of  the  face  resting  on  a  low  pillow.  A  Simon 
speculum  with  a  curved  blade  is  introduced  into  the  vagina,  and  b}^  it 
the  perineum  is  retracted.  The  air  balloons  out  the  vagina,  and  the 
body  of  the  uterus  is  assisted  in  the  excursion  by  making  traction  upon 
the  cervix  with  a  vulsellum  forceps.  By  bringing  the  uterus  to  a  lower 
level  the  fundus  may  pass  from  under  the  promontory  of  the  sacrum. 
Further  aid  may  be  given  by  pressing  upon  the  body  of  the  uterus  from 
the  posterior  vaginal  fornix  with  a  ball  of  absorbent  cotton  placed 
upon  a  curved  dressing  forceps.  When  the  uterus  is  fixed  by  adhesions, 
or  firmly  wedged  in  the  hollow  of  the  sacrum,  failure  is  likely  to  ensue. 


364  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

Retaining  the  Uterus  in  Position. — After  replacing  the  uterus 
some  means  of  support  must  be  devised.  In  recent  displacements 
conservative  measures  should  be  adopted.  If  tenderness  exists  as  the 
result  of  congestion  or  an  inflammaton'  lesion- in  the  pelvis,  the  uterus 
may  be  temporarily  supported  by  tampons  of  lambs'  wool. 

It  is  in  recent  displacements  that  the  Hodge-Smith  pessaries  are  of 
greatest  service,  but  they  are  not  to  be  worn  when  they  occasion 
discomfort. 

General  Treatment. — Here,  as  in  all  pelvic  disorders,  it  is  essential 
that  the  condition  of  the  general  health  must  be  looked  to  if  good  results 
are  to  be  obtained. 

Careful  regulation  of  the  diet,  of  the  bowels,  of  exercise,  and  of 
rest  are  essential  to  all  gynecological  cases,  and  are  to  be  conducted 
in  accordance  with  the  rules  laid  down  in  previous  chapters. 

An  important  factor  for  consideration  is  that  of  dress.  The  even 
distribution  of  the  clothing  over  the  body  and  the  avoidance  of  waist 
constriction  and  traction  are  to  be  borne  in  mind.  (See  Chapter  XII.) 
Stimulating  baths  should  be  employed  daily.    (See  page  189.) 

Treatment  of  Chronic  Retroversioflexicn. — In  the  treatment  of  chronic 
retrodisplacements  of  the  uterus  no  permanent  correction  can  be  obtained 
by  the  conservative  measures  employed  in  the  management  of  acute 
displacements.  The  uterus  may  be  replaced  by  bimanual  manipulations, 
but  the  displacement  will  promptly  recur  unless  a  suitable  support  is 
provided;  again,  the  uterus  may  be  retained  in  position  by  tampons 
or  pessary,  but  recurrence  will  follow  the  withdrawal  of  the  support. 

It  therefore  follows  that  operative  interference  is  demanded  for  the 
permanent  correction  of  chronic  retrodisplacements  of  the  uterus. 

The  question  may  arise.  Would  you  advise  the  application  of  the 
pessary  in  any  case?  The  author's  answer  to  this  question  would  be 
that,  in  chronic  displacements  causing  symptoms,  his  choice  would  be 
in  favor  of  an  operation  unless  contra-indicated  by  existing  physical 
conditions,  which  would  make  the  operation  hazardous,  or  by  the 
choice  of  the  patient  in  favor  of  the  pessary  after  full  knowledge  that 
the  pessary  can  at  best  give  only  symptomatic  relief  so  long  as  it  is 
worn.  The  author  favors  operation  in  these  cases  because  of  the  per- 
manent and  speedy  results  obtained,  and  because  it  affords  opportunity 
for  the  correction  of  the  causes  and  results  of  the  lesion.  In  short,  a 
condition  of  health  may  be  thereby  restored  and  by  no  other  means. 

In  operating  for  displacements  of  the  uterus  the  surgeon  must  bear 
in  mind  that  the  causal  and  resultant  factors  are,  as  a  rule,  of 
greater  importance  than  the  displacement.  An  uncomplicated  retrodis- 
placement  may  not  demand  operative  interference,  but  a  retrodis- 
placement  associated  with  relaxation  of  the  uterine  supports,  with 
laceration  of  the  cervix  and  pelvic  floor,  with  tumor  formations  and 
with  chronic  inflammatory  lesions,  in  the  uterus  and  its  adnexse,  do 
demand  operative  interference — not  so  much  because  of  the  displace- 
ment of  the  uterus,  but  more  because  of  existing  lesions  which  stand 
in  relation  to  the  displacement  as  causes  or  effects. 


VENTROSUSPENSION  OF  THE  UTERUS  365 

These  coexisting  lesions  can  be  corrected  along  with  the  replacing 
of  the  uterus  and  under  a  single  anesthesia. 

No  attempt  will  be  made  to  describe  the  many  operations  designed 
for  the  correction  of  retroversioflexion  of  the  uterus.  A  large  number 
of  them  possess  no  merit  and  some  of  them  are  positively  harmful. 
The  author  desires  to  present  only  those  operations  which  in  his  judg- 
ment have  the  greatest  merit. 

Ventrosuspension. — Ventrosuspension  of  the  uterus,  once  in  general 
favor,  is  now  generally  supplanted  by  other  equally  effective  and  less 
objectionable  operations  upon  the  uterosacral  and  round  ligaments. 

Howard  Kelly,  who  introduced  this  method  of  correcting  a  retro- 
versioflexion of  the  uterus  in  1886,  still  vigorously  defends  his  method. 
Having  performed  more  than  one  thousand  ventrosuspensions,  his 
conclusions  deserve  careful  consideration. 

Ventrosuspension  of  the  uterus  has  been  objected  to  because  it 
substitutes  a  fixed,  unnatural  anteflexion  for  a  retroflexion,  because  it 
crowds  the  uterus  upon  the  bladder  and  interferes  with  its  distension, 
and  finally  because  it  interfers  with  the  normal  development  of  the 
pregnant  uterus. 

Kelly  answers  these  arguments  by  stating  from  his  large  experience 
that  the  actual  fixation  to  the  abdominal  wall  lasts  but  a  short  time, 
that  within  a  few  months  the  uterus  lies  at  a  distance  from  the  abdomi- 
nal wall  in  a  position  of  easy  anteflexion.  In  this  position,  he  says, 
the  suspension  does  not  interfere  with  the  distension  of  the  bladder 
nor  with  the  development  of  pregnancy.  He  argues  that  it  is  only 
when  the  uterus  is  firmly  fixed  to  the  abdominal  wall,  not  suspended, 
that  serious  trouble  arises. 

The  author  performed  ventrosuspension  to  the  exclusion  of  all  other 
methods  prior  to  1904.  Since  that  time  he  has  given  preference  to 
the  round  ligament  operations  described  below.  He  has  discriminated 
against  the  operation  because  of  the  frequency  with  which  the  suspen- 
sion band  has  been  known  to  so  stretch  as  to  permit  of  a  recurrence  of 
the  displacement;  because  of  the  occasional  dragging  pains  at  the 
seat  of  the  scar,  and,  more  than  all,  because  of  the  serious  obstetrical 
complications  which  he  believes  follow  to  an  unjustifiable  degree.  In 
view  of  the  obstetrical  complications  which  may  follow  this  operation, 
tbf  author  is  of  the  opinion  that  ventrosuspension  should  never  be 
performed  when  there  is  a  possibility  of  future  childbearing.  In  this 
respect  the  operations  upon  the  round  ligaments  have  the  advantage 
of  creating  no  obstacle,  even  though  they  may  be  no  more  permanent 
in  their  results. 

Technic  of  Ventrosuspension. — Step  1. — The  usual  median  incision 
is  made  in  the  abdomen,  having  previously  catheterized  the  bladder. 
This  incision  need  not  be  longer  than  two  inches  unless  required  for 
the  correction  of  other  lesions. 

Step  2. — The  fundus  is  elevated  by  the  index  and  middle  fingers 
introduced  through  the  incision.  If  the  uterus  is  bound  by  adhesions 
these  must  be  severed  by  the  fingers  or  scissors.     After  freeing  the 


366 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


uterus,  attention  is  directed  to  the  appendages.  These  are  dealt  with 
according  to  the  demands  of  existing  lesions.  Other  lesions,  such  as  a 
chronic  appendicitis,  are  disposed  of  and  the  pelvis  left  free  of  all 
abnormalities  before  the  uterus  is  suspended.  After  completing  the 
work  required  in  the  pelvis  the  fundus  is  pushed  forward  under  the 
symphysis  to  the  position  of  anteflexion.  This  is  done  by  the  finger; 
no  tenacula  forceps  are  required. 

Step  3. — With  the  posterior  surface  of  the  fundus  directed  toward 
the  abdominal  incision,  a  medium-sized  silk  suture  in  a  round  curved 
needle  is  passed  through  the  peritoneum  and  subperitoneal  connective 
tissue  at  a  point  near  the  lower  end  of  the  incision,  then  transfixes 
the  fundus  on  its  posterior  surface  to  a  depth  of  about  one-eighth  inch, 
and  finally  passes  through  the  peritoneum  and  subperitoneal  connective 
tissue  of  the  opposite  side  and  at  a  point  corresponding  to  its  entrance. 
The  suture  is  then  securely  tied,  avoiding  too  tight  constriction,  and 
bringing  the  peritoneal  surfaces  together  in  close  proximity  to  the  uterus 
at  the  point  of  transfixion. 


Fig.  252 


Suspension  of  the  uterus.  Diagram  showing  the  position  of  the  uterus  in  retroflexion  in  dotted 
line,  and  the  position  of  the  uterus  held  in  anteflexion  by  the  two  suspensory  sutures.  Note  the 
yielding   of   the  peritoneum.     (Kelly.)  , 


A  second  suture  is  similarly  passed  at  a  point  one-half  inch  higher 
in  the  incision  and  transfixing  the  uterus  a  half-inch  back  of  the  first 
suture. 

Step  4. — After  tying  the  two  sutures  and  cutting  close  to  the  knots 
a  careful  examination  is  made  with  the  finger  to  make  sure  that  no 


VENTROSUSPENSION  OF  THE   UTERUS 


367 


loops  of  intestine  or  portion  of  omentum  have  become  engaged  between 
the  uterus  and  the  abdominal  wall.  The  abdominal  wall  is  then  closed 
in  the  usual  way. 

Emphasis  is  placed  upon  the  anteflexion  of  the  uterus  in  order  that 
the  intra-abdominal  pressure  may  be  directed  to  the  posterior  surface 
of  the  uterus,  thereby  aiding  in  maintaining  the  uterus  in  its  normal 
position.  Were  the  uterus  transfixed  high  upon  the  fundus  in  a  line 
with  the  tubes  the  tendency  would  be  for  the  intra-abdominal  pressure 
to  force  the  uterus  downward  and  backward  rather  than  forward. 

Fig.  253 


Adhesions  stretched  out  to  form  new  artificial  ligaments. 


After-treatment. — During  the  three  or  four  days  following  the 
operation,  the  urine  must  be  evacuated  every  three  to  six  hours.  No 
more  than  six  ounces  of  urine  should  be  permitted  to  accumulate  in  the 
bladder  for  fear  of  tearing  out  the  sutures.  During  this  time  the  catheter 
should  be  used  only  when  the  patient  is  unable  to  void  the  urine. 

The  patient  should  be  allowed  to  change  her  position  from  side  to 
side.  After  ten  days  of  confinement  in  bed  she  may  be  permitted  to 
sit  in  a  chair  and  to  walk  about.  Before  doing  so  it  is  well  to  introduce 
a  Hodge-Smith  pessary,  which  should  be  M^orn  for  eight  to  twelve 


368  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

weeks.  Doubtless  the  wearing  of  the  pessary  will  have  its  influence  in 
preventing  a  recurrence  of  the  displacement. 

Precautions. — Kelly  advises  against  the  suspension  of  a  pregnant 
uterus  for  fear  of  fixation  resulting  in  a  uterus  which  is  growing  so 
rapidly  and  is  so  vascular. 

He  also  advises  against  the  suspension  of  a  uterus  bleeding  at  the 
fundus  from  broken  adhesions  or  from  wounds  made  by  tenacula 
forceps. 

One  more  precaution  is  cited  by  Kelly,  that  of  fixing  the  uterus  low 
in  the  abdominal  incision  so  that  the  uterus  is  not  more  than  3  or  4 
cm.  above  the  symphysis.  When  suspended  at  a  high  level  antefiexion 
is  not  obtained  and  the  intra-abdominal  pressure  tends  to  force  the 
uterus  backward. 

Care  should  be  taken  not  to  wound  the  peritoneal  covering  of  the 
fundus  by  forceps  and  tenacula  for  fear  of  the  development  of  adhesions 
between  the  uterus  and  abdominal  wall,  thereby  creating  a  fixation 
of  the  uterus.  Failure  to  heed  these  precautions  doubtless  accounts 
for  many  of  the  unfortunate  results  obtained  by  surgeons. 

While  the  author  no  longer  practises  the  Kelly  method  of  suspension, 
believing  that  other  methods  are  preferable,  he  is  free  to  recognize  the 
merits  of  the  operation  in  selected  cases. 

Ventrofixation.  —  The  fixing  of  the  uterus  to  the  rectus  muscles  is 
an  operation  which  should  seldom  be  employed.  It  is  not  only  objec- 
tionable when  done  in  the  childbearing  period,  but  at  all  times  it 
prohibits  the  physiological  range  of  motion  with  which  the  uterus  is 
normally  endowed. 

Ventrofixation  of  the  uterus  gives  rise  to  the  following  difficulties  in 
yregnancy  and  labor: 

1.  Retraction  of  the  scar  with  pain. 

2.  Cervix  displaced  backward  and  upward. 

3.  Overdistension  of  the  posterior  wall  of  the  uterus  and  the  develop- 
ment of  a  tumorous  mass  in  the  anterior  wall  of  the  uterus,  which  may 
obstruct  the  passage  of  the  child  in  labor. 

4.  Liability  to  the  spontaneous  interruption  of  pregnancy. 

5.  The  term  of  pregnancy  may  be  prolonged. 
Difficulties  Arising  from  Ventrofixation  during  Labor. 

1 .  Ineffective  uterine  contractions  due  to  the  thinning  of  the  posterior 
wall  of  the  uterus. 

2.  Passage  of  the  fetus  obstructed  by  the  tumorous  mass  in  the 
anterior  wall  of  the  uterus. 

3.  Slow^  and  imperfect  dilatation  of  the  cervix  due  to  its  displacement 
upward  and  backward. 

Todd- Gilliam  Operation. — This,  in  the  opinion  of  the  author,  is  an 
excellent  operation  in  all  cases  of  retroversioflexion  requiring  operation. 
The  results  have  been  most  satisfactory  in  more  than  one  hundred 
cases  of  the  author  and  the  simplicity  of  the  technic  commends  itself. 
There  is  no  restriction  in  the  mobility  of  the  uterus,  and  no  adhesive 
bands  to  give  rise  to  intestinal  obstruction.   The  uterus  is  suspended  by 


RETROVERSIOFLEXIOX  OF   THE   UTERUS 


369 


the  strongest  part  of  the  round  hgament,  which  is  capable  of  much 
resistance.  No  comphcations  in  pregnancy  are  to  be  anticipated 
inasmuch  as  the  uterine  end  of  the  round  Hgaments,  which  suspend  the 
uterus,  are  capable  of  h^-pertrophy,  of  elongation  as  the  uterus  rises 
in  the  abdomen,  and  of  retraction  after  delivery. 

It  is  argued  that  the  round  ligaments,  in  their  changed  position, 
present  two  cords  in  the  anterior  segment  of  the  peh'is  which  endanger 
the  patient  to  intestinal  strangulation.  Theoretically  the  argument 
holds  good  but  experience  proves  that  the  accident  has  seldom  occmred. 

To  obviate  this  objection  Frank  F.  Simpson  has  devised  a  modi- 
fication of  the  Todd-Gilliam  operation.     (See  page  .376.) 


Fig.  254 


Loops  of  round  ligaments  stitched  to  the  sheath  of  the  recti  muscles  in  the  Todd-Gilliam  operation 


Techxic  of  Todd-Gilliam  Operatiox. — The  following  are  the  steps 
of  the  operation  as  practised  by  the  author: 

1.  Median  abdominal  incision. 

2.  Reflect  skin  and  subcutaneous  fat  from  external  sheath  of  the 
rectus  at  the  lower  end  of  the  incision. 

3.  Button-hole  external  sheath  with  knife,   one-half  inch  on  each 
side  at  the  lower  angle  of  incision. 

4.  Force  twelve-inch  artery  forceps  of  proper  cu^^-e  through  sheath, 
rectus  muscle,  and  peritoneum. 

5.  Grasp  round  ligament  one  inch  from  the  cornua  of  uterus  and 
■^"ithdraw  the  loop  of  ligament  through  the  sheath  of  the  rectus. 

6.  Repeat  the  same  process  on  opposite  side. 
24 


370 


MALPOSITIONS  OF  THE  GEXITAL  ORGAXS 


7.  Close  parietal  peritoneum  with  a  running  suture  of  plain  catgut 
No.  1. 

8.  Close  sheath  of  rectus  bv  interrupted  ten-day  chromicized  catgut 

No.  2. 

9.  Spread  loop  of  round  ligaments  over  sheath  of  rectus  and  stitch 
margins  ^\-ith  No.  2  plain  catgut.  Reinforce  vriih  one  or  more  fixation 
sutures  of  silk  or  linen. 

Fig.  255 


The  hemostatic  forceps  are  seen  perforating  the  broad  ligament  from  behind  to  its  anterior  aspect 
on  which  lies  the  rovind  ligament.  A  pair  of  tissue  forceps  are  grasping  the  round  ligament  and 
carr\-ing  it  into  the  bite  of  the  perforating  hemostatic  forceps.     (Baldy.) 


10.  Anchor  round  ligament  at  the  point  of  exit  through  the  sheath 
of  the  rectus  ^dth  linen. 

11.  Close  skin  incision  with  a  subcutaneous  suture  of  silkworm-gut 
or  horse-hair. 

All  lesions  within  the  pehds  should  be  attended  to  before  the  above 
steps  are  taken. 


RETROVERSIOFLEXION  OF  THE  UTERUS 


371 


The  Gilliam  operation  is  described  in  full  in  the  Jour.  Amer.  Med. 
Assoc,  September  18,  1900.  It  will  be  noted  that  the  author  has 
made  some  modifications  in  technic,  but  the  essential  steps  of  the 
operation  do  not  differ. 

Retro-uterine  Looping  of  the  Round  Ligaments. — Credit  is  due  Web- 
ster and  Baldy  for  introducing  and  perfecting  this  operation.  The 
author  has  practised  this  operation  with  great  satisfaction.     It  has 

Fig.  256 


The  round  ligament  in  the  grasp  of  the  hemostatic  forceps  and  in  process  of  being  drawn  through 
the  broad  ligament  to  its  posterior  aspect.     (Baldy.) 


the  advantage  over  the  Todd-Gilliam  operation  in  that  the  direction 
of  traction  made  by  the  round  ligaments  does  not  differ  essentially 
from  the  normal,  but  it  suffers  in  comparison  with  the  Todd-Gilliam 
operation,  in  that  the  weaker  part  of  the  round  ligament  is  left  to 
support  the  uterus. 


372 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


Techxic  of  Operation. — The  usual  abdominal  incision  is  made  in 
the  median  line.  Before  proceeding  to  correct  the  displacement  of 
the  uterus,  all  pathological  conditions  within  the  pelvis  should  be 
corrected.  After  completing  this  preliminary  work  the  operator  pro- 
ceeds with  the  replacement  of  the  uterus.  The  round  ligaments  are 
grasped  by  hemostatic  forceps  near  the  uterine  cornua  and  the  uterus 
is  drawn  forward  to  the  pubes.     Long  hemostatic  forceps  are  forced 


Fig.  257 


Both  round  ligaments  drawn  to  the  posterior  portion  of  the  broad  ligament  and  approaching 

each  other.     (Baldy.) 


through  the  broad  ligament  from  behind  at  a  point  underneath  the 
ovarian  ligament  and  close  to  the  side  of  the  uterus.  They  emerge 
from  the  broad  ligament  immediately  above  the  round  ligament,  and 
are  then  opened  and  made  to  grasp  the  round  ligament  about  two 
inches  from  its  uterine  attachment.  The  forceps  are  then  retracted 
and  the  loop  of  round  ligament  is  brought  through  the  broad  ligament 
upon  the  posterior  surface  of  the  uterus.  A  similar  procedure  is  carried 
out  on  the  other  side.     Before  stitching  the  loops  to  the  uterus  it  is 


RETROVERSIOFLEXION  OF  THE  UTERUS 


373 


well  to  scarify  the  surface  of  the  uterus  over  which  the  loop  is  to  be 
adjusted.  The  loops  of  round  ligament  are  then  spread  out  over  this 
area  and  fixed  to  the  uterus  with  fine  linen  sutures.  Care  should  be 
exercised  to  expose  the  peritoneal  surface  of  the  ligaments.  When 
the  opening  in  the  broad  ligament  is  unduly  large  it  is  closed  with  one 
or  more  catgut  sutures. 


Fig.  258 


Both  round  ligaments  are  united  to  each  other,  and  at  two  points  to  the  uterus  itself, 
operation  is  completed.     (Baldy.) 


and  the 


When  the  tubes  have  been  removed  the  round  ligaments  are  brought 
over  the  broad  ligaments  rather  than  through  them. 

Webster  does  not  approve  of  this  operation  when  the  distal  ends  of 
the  round  ligaments  are  frail.  In  this  event  he  prefers  the  Todd- 
Gilliam  operation.  He  further  advises  the  wearing  of  a  Hodge  or 
Albert-Smith  pessary  for  several  months  after  the  operation  to  prevent 
recurrences  of  the  displacement. 

Willis'  Operation.— An  admirable  procedure  is  the  shortening 
of  the  round  ligaments  and   the  broad  ligaments   as  presented  by 


374 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


Dr.  A.  Murat  Willis,  in  the  Journal  of  Surgery,  Gynecology,  and  Obstetrics, 
June,  1912,    Following  are  the  special  features  of  the  operation:- 


Fig.  259 


Showing  grasping  of  each  round  ligament.     (Willis.) 
Fig.  260 


Showing  passage  of  linen  thread,  on  a  small,  round,  curved  needle,  through  half  of  one  round  ligament, 
then  through  a  good  bite  of  the  uterus,  then  through  half  of  the  other  ligament.     (Willis.) 

1.  Maximum  shortening  of  the  broad  ligaments,  which  have  much 
to  do  in  supporting  the  uterus, 

2.  Round  ligaments  advanced  in  their  normal  direction. 


RETROVERSIOFLEXION  OF  THE  UTERUS  375 

3.  Line  of  sutures  placed  where  intestinal  adhesions  are  not  likely  to 
occur. 

4.  No  additional  bands  created  that  would  subject  the  patient  to  a 
possible  intestinal  obstruction. 

5.  Simplicity  of  technic. 

Fig.  261 


Plication  of  the  broad  ligament  to  within  one-half  to  three-quarters  inch  of  the  bladder.    (Willis.) 

Fig.  262 

1 


Showing  further  reinforcement  by  means  of  an  interrupted  suture.     (Willis.) 

The  technic  of  the  author  is  as  follows: 

Step  1.— Each  round  ligament  is  grasped  by  a  hemostatic  forceps 
about  two  inches  from  its  uterine  end.    At  this  point  the  ligament  on 


376 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


the  one  side  is  transfixed  with  a  fine  linen  thread  on  a  small  round 
needle.  The  needle  and  thread  are  then  passed  through  the  anterior 
wall  of  the  fundus  and  on  to  a  corresponding  point  in  the  opposite 
round  ligament.  This  suture  is  tied,  thereby  bringing  the  round 
ligaments  together  in  the  median  line. 

Siej)  2. — The  same  suture  is  brought  down  in  the  median  line  of  the 
uterus  and  is  passed  in  a  continuous  manner  through  the  broad  liga- 
ments and  uterus.  In  this  manner  the  broad  ligaments  are  materially 
shortened. 

Step  3. — Finally  an  interrupted  suture  of  linen  is  passed  through  the 
round  ligament  and  fundus,  midway  between  the  natural  insertion  of 
the  round  ligament  and  the  median  line  of  the  fundus. 


Fig.  263 


Third  step:  The  forceps  of  proper  curve,  having  passed  through  the  fascia  and  obliquely  through 
the  rectus  muscle,  skirts  beneath  the  parietal  peritoneum  to  the  internal  abdominal  ring,  where  it 
passes  between  the  layers  of  the  broad  ligament  and  follows  the  course  of  the  round  ligament  to  one 
and  one-half  inches  of  the  uterus.  At  that  point  it  penetrates  the  peritoneum,  entering  the  peritoneal 
cavity  for  the  first  time,  and  then  grasps  the  round  ligament  proximal  to  the  guide  forceps  (G.  F.). 
(Simpson.) 

Simpson  Operation. — To  overcome  the  objection  to  the '  various 
operations  designed  to  correct  retrodisplacements  of  the  uterus,  i.  e., 
strangulation  of  the  bowel  caused  by  the  formation  of  bands  passing 
through  the  pelvic  cavity,  Simpson  has  devised  a  means  of  drawing 
the  round  ligaments  through  the  folds  of  the  broad  ligaments  and 
fastening  the  round  ligaments  beneath  the  sheath  of  the  rectus  muscle. 
The  steps  of  the  operation  are  as  follows: 


RETROVERSIOFLEXION  OF   THE   UTERUS 


377 


1.  Median  abdominal  incision. 

2.  Round  ligament  caught  one  and  one-half  inches  from  the  uterus 
and  the  parietal  peritoneum  at  the  point  of  the  internal  inguinal  ring. 

3.  Skin  retracted  and  the  fascia  punctured  with  scalpel  about  one 
and  one-half  inches  to  the  side  of  the  lower  angle  of  the  incision. 

4.  Forceps  of  proper  curve  passed  through  the  fascia  and  rectus 
muscle,  and  entering  the  broad  ligament  at  the  internal  ring.  The 
forceps  passes  beneath  the  peritoneum  and  by  the  side  of  the  round 
ligament  until  it  reaches  the  hemostat  holding  the  round  ligament. 

5.  The  forceps  is  forced  through  the  peritoneum  and  grasps  the  round 
ligament,  and  is  drawn  out  through  the  tunnel  made  by  the  forceps. 

6.  The  loop  of  round  ligament  is  stitched  to  the  under  surface  of 
the  fascia  of  the  rectus.  This  stitch  fixes  the  loop  and  closes  the  rent 
in  the  fascia.    A  similar  process  is  carried  out  on  the  other  side. 

Fig.  264 


Fourth  step:  The  margin  of  peritoneal  wound  having  been  caught  by  hemostatic  forceps  {H), 
the  curved  forceps  (C  F.)  grasps  the  round  ligament.  By  withdrawal  of  the  curved  forceps  the  round 
ligament  is  drawn  out  through  the  canal  made  by  the  forceps.     (Simpson.) 


Noble  Operation  for  Shortening  the  Uterosacral  Ligaments. — George 
H.  Noble  has  devised  a  simple  and  effective  means  of  shortening  the 
uterosacral  ligaments.  The  operation  consists  in  passing  a  curved 
needle  threaded  with  fine  linen  through  the  uterosacral  ligament  at 
the  juncture  of  the  middle  and  posterior  third,  next  passing  through 
the  posterior  aspect  of  the  supravaginal  portion  of  the  cervix,  and 
finally  through  the  opposite  uterosacral  ligament  at  a  point  correspond- 
ing to  the  initial  point  of  entrance.    It  is  desired  to  reproduce  a  retro- 


378 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


uterine  pouch  of  normal  size,  hence  the  points  of  transfixion  of  the 
uterosacral  folds  vary  from  a  midpoint  to  the  juncture  of  the  middle 
and  posterior  thirds. 

When  the  suture  is  tied,  as  in  Fig.  266,  there  will  be  a  single  suture 
approximation  at  three  points:  One  on  the  posterior  surface  of  the 
cervix,  and  the  other  two  on  either  side  of  Douglas'  pouch.  With  a 
single  suture  two  important  things  are  accomplished:  the  cervix  is 
retracted  backward  and  upward,  and  the  pouch  of  Douglas  is  reduced 
in  size.  The  Noble  operation  is  usually  performed  in  connection  with 
the  shortening  of  the  round  ligaments. 


Fig.  265 


Fig.  266 


Shortening  of  the  uterosacral  ligaments.     Noble  operation. 


Alexander-Adams  Operation. — This  operation  was  received  with  great 
favor  at  a  time  when  intra-abdominal  operations  were  avoided  for 
fear  of  infection,  and  when  they  did  not  appreciate,  as  we  now  do, 
the  prevalence  and  influence  of  the  various  pelvic  lesions  which  so 
commonly  complicate  retrodisplacements  of  the  uterus. 

While  the  extraperitoneal  shortening  of  the  round  ligaments  is  yet 
to  be  viewed  as  the  ideal  operation  in  uncomplicated  cases,  our  diag- 
nostic ability  has  not  attained  that  degree  of  perfection  which  enables 
us  to  exclude  with  absolute  certainty  such  lesions  as  adhesions,  chronic 
appendicitis,  cystic  degeneration  of  the  ovaries,  and  thin-walled  cystic 
enlargements  of  the  tubes  and  ovaries.  Therefore,  the  author  concludes 
that  the  Alexander-Adams  operation,  while  ideal  in  uncomplicated 
cases,  should  be  discriminated  against  in  favor  of  operations  which 
necessitate  the  opening  of  the  abdomen,  thereby  affording  opportunity 
for  the  inspection  of  the  pelvic  organs. 

Figs.  267,  268, 269,  and  270,  present  the  several  steps  of  the  operation. 


RETROVERSIOFLEXION  OF  THE  UTERUS 


379 


Vaginal  Shortening  of  the  Uterosacral  Ligaments. — Jellette  describes 
a   new  operation   designed  to   shorten  the  uterosacral  Hgaments  in 


Fig.  267 


Alexander-Adams  operation.     Step  1-     Oblique  incision  through  the  skin  and  superficial  fascia, 
exposing  the  fascia  of  the  external  oblique  and  the  external  abdominal  ring. 


Fig.  26S 


Step  2.     Round  ligament  grasped  by  forceps  and  severed  at  its  distal  attachment. 

prolapsus  uteri.  The  operation  can  be  combined  with  other  procedures, 
such  as  plastic  operations  on  the  pelvic  floor  and  the  shortening  of 
the  round  ligaments  through  an  abdominal  incision. 


380 


MALPOSITIONS  OF   THE  GENITAL  ORGANS 


Technic  of  Operatiox. — The  first  step  consists  in  dividing  the 
vaginal  mucous  membrane  by  a  circular  incision  as  in  performing  a 
vaginal  hysterectomy;   next  in  stripping  the  vaginal  mucosa  upward 


Fig.  269 


Step  3.     Splitting  the  fibers  of  the  external  oblique  and  exposing  the  round  ligament  in  the 

inguinal  canal. 


Step  4.     Traction  made  on  the  round  ligament.    Round  ligament  stitched  with  linen  to  the 
sheUdng  margin  of  Poupart's  ligament. 


RETROVERSIOFLEXION  OF  THE   UTERUS 


381 


the  entire  length  of  the  cervix,  thereby  exposing  the  insertion  of  the 
uterosacral  Hgaments. 

The  second  step  consists  in  catching  each  ligament  with  forceps  and 
severing  with  scissors  the  ligaments  close  to  the  uterus.  When  there  is 
doubt  as  to  the  location  of  the  ligaments,  they  can  be  easily  identified 
by  opening  into  the  cul-de-sac  and  introducing  the  finger.  . 


Fig.  271 


Shortening  of  the  uterosacral  hgaments.  The  mucous  membrane  of  the  vagina  has  been  divided 
circularly  around  the  cervix  and  pushed  upward  so  as  to  expose  the  uterine  insertion  of  the  ligaments. 
L,  ligament;  PV,  cut  edge  of  mucous  membrane  of  posterior  vaginal  wall.     (Jellette.) 


The  third  step  consists  in  bringing  the  divided  ends  of  the  ligaments 
forward  in  front  of  the  cervix  and  stretching  them  together  and  to  the 
anterior  surface  of  the  cervix.  Before  passing  the  sutures,  the  cervix 
is  pushed  into  its  normal  position  so  that  the  required  amount  of 
shortening  of  the  ligaments  may  be  known. 

Hernia  of  the  Uterus  (Hysterocele) . — Hernia  of  the  uterus  is  of  rare 
occurrence.  The  rupture  usually  occurs  through  the  inguinal  canal, 
less  often  through  the  crural  ring.  The  only  two  recorded  cases  of 
crural  hernia  are  those  of  Bowen  and  Duges.  Fifteen  cases  of  inguinal 
hernia  of  the  uterus  were  collected  by  Kiistner;  of  these,  eight  were 


382 


MALPOSITIONS  OF  THE  GENITAL  ORGANS 


pregnant.  The  explanation  of  the  development  of  the  hernia  is  usually 
given  as  traction  made  upon  the  uterus  by  adhesions  binding  the 
hernial  sac  to  the  uterus  and  drawing  the  uterus  within  the  sac.  There 
is  generally  some  associated  anomaly  in  development. 

The  diagnosis  is  made  by  palpation  and  by  an  exploratory  incision. 
Hernia  of  the  uterus  through  the  linea  alba  may  follow  ventrosuspension. 
Plate  VI  represents  the  hernia  of  a  uterus  in  the  fourth  month  of 
pregnancy. 


Fig.  272 


Shortening  of  the  uterosacral  ligaments.  The  ligaments  have  been  freed  from  their  attachment 
to  the  uterus  and  brought  around  in  front  of  the  cervix.  The  fixing  sutures  are  inserted.  L,  ligament; 
AV,  anterior  vaginal  wall.     (Jellette.) 


MALPOSITIONS  OF  THE  FALLOPIAN  TUBES 

Normal  Position  and  Anatomy. — The  Fallopian  tubes  are  two  in 
number,  one  on  either  side  of  the  uterus.  They  run  sinuously  from  the 
horn  of  the  uterus  toward  the  side  of  the  pelvis  and  lie  enclosed  between 
the  two  layers  of  the  broad  ligament  at  its  upper  margin.  The  average 
length  of  the  tubes  is  4  to  4.5  inches. 

We  speak  of  tlu-ee  segments  of  the  tube:  the  isthmus,  the  ampulla, 
and  the  fimbriated  end  or  pavilion. 


MALPOSITIONS  OF  THE  FALLOPIAN  TUBES  383 

The  isthmus  runs  a  straight  course  and  communicates  directly  with 
the  uterine  cavity.  Its  average  diameter  is  2  to  3  mm,  and  its  lumen 
will  not  more  than  admit  a  bristle. 

The  ampulla  is  the  midportion  of  the  tube;  it  runs  in  a  curved  direc- 
tion; its  wall  is  the  thickest  portion  of  the  entire  tube;  the  lumen  will 
admit  the  passage  of  a  uterine  sound,  and  the  entire  thickness  of  this 
segment  of  the  tube  is  6  to  8  mm. 

Fig.  273 


Shortening  of  the  uterosacral  ligaments.  The  sutures  which  fix  the  ligaments  in  their  new  position 
are  tied.  L,  ligament.  The  cervix  is  shown  here  at  the  level  of  the  vaginal  outlet  for  the  sake  of  clear- 
ness. In  practice  it  would  lie  high  up  in  the  vagina.  The  sutures  which  bring  back  the  vaginal  cuff 
into  position  would  also  be  inserted  at  this  stage,  and  tied  posteriorly  and  laterally.  Anteriorly  they 
are  tied  as  soon  as  the  suture  of  the  ligament  is  complete.     (Jellette.) 

The  fimbriated  end  of  the  tube  lies  free  in  the  pelvic  cavity.  It  is 
expanded  into  a  funnel  shape  (inf undibulum) ,  and  around  its  free  outer 
margin  are  primary  and  secondary  fimbriae,  one  of  which  runs  to  the 
ovary. 

On  cross-section  the  Fallopian  tube  is  seen  to  be  composed  of  three 
layers,  namely,  peritoneal,  muscular,  and  mucous.  Connective-tissue 
and  elastic  fibers  lie  between  the  peritoneal  and  muscular  la^'erSo  The 
muscular  layer  consists  of  longitudinal  and  circular  muscle  fibers;  the 
mucous  membrane  is  lined  with  a  single  layer  of  columnar,  ciliated 
cells.  No  glands  are  found  in  the  mucous  membrane,  which  is  much 
folded  in  a  longitudinal  direction,  especially  in  the  ampulla. 

The  anatomical  points  of  special  clinical  significance  are: 


384  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

1.  The  tube  provides  a  direct  passageway  from  the  outer  world, 
through  the  vulvar  orifice,  vagina,  uterus,  and  to  the  peritoneal  cavity. 

2.  The  infundibular  portion  of  the  tube  lies  free  in  the  peh'ic  peri- 
toneal cavity. 

3.  The  isthmus  and  ampulla  lie  between  the  layers  of  the  broad 
ligament. 

The  above  anatomical  points  will  be  found  to  be  significant  in  relation 
to  tubal  infections  and  to  tubal  pregnancy. 

Changes  in  the  Position. — These  changes  may  be  congenital,  but 
are  more  often  acquired.  In  congenital  malposition  of  the  tubes  there 
is  usually  a  malposition  or  maldevelopment  of  the  uterus.  In  a  uterus 
bicornis  the  tubes  lie  more  to  the  sides  of  the  pelvis  than  is  normal. 
In  a  rudimentary  uterus  the  tubes  lie  below  the  normal  level.  Con- 
genital hernia  of  one  or  both  tubes  is  a  rare  finding. 

Much  more  frequent  are  acquired  displacements  of  the  tubes.  When 
the  tube  becomes  enlarged  and  increases  in  weight,  it  tends  to  fall  to  a 
lower  level  at  the  side  of  or  behind  the  uterus.  Adhesions  may  pull 
the  tube  in  any  direction,  and  all  swellings,  whether  inflammatory  or 
newgrowths,  push  the  tubes  into  malpositions.  Any  displacement  of 
the  uterus  will  almost  invariably  displace  the  tubes. 

MALPOSITIONS  OF  THE  OVARIES 

Normal  Position  and  Histology. — Anatomy. — The  ovaries  are  two  in 
number,  lying  behind  the  broad  ligaments  on  a  level  with  the  brim 
of  the  pelvis,  midwa}'  between  the  horn  of  the  uterus  and  the  psoas 
muscles.  The  ovary  is  oval  in  shape  and  about  the  size  of  an  almond. 
The  average  measurements,  as  given  by  Farre,  are:  longitudinal 
diameter,  one-third  inch;  transverse  diameter,  three-quarters  inch; 
perpendicular  diameter,  three-eighths  inch.  The  anterior  border 
(hilum)  is  flat,  and  is  attached  to  the  broad  ligament;  the  posterior 
border  is  convex  and  free.  The  ovary  lies  in  a  shallow  concavity  formed 
by  the  posterior  layer  of  the  broad  ligament.  This  fossa  of  the  broad 
ligament  is  a  remnant  of  the  peritoneal  pouch  in  which  the  ovary  of 
the  rat  and  other  mammalians  is  enclosed.  Such  a  fossa  was  observed 
in  a  case  operated  by  J.  Clarence  Webster. 

The  ligaments  of  the  ovary  are  two  in  number — the  ovarian  ligament 
and  the  infundibulo-pelvic  ligament.  In  addition  to  these  ligaments 
the  ovary  is  attached  at  its  hilum  or  anterior  border  to  the  posterior 
layer  of  the  broad  ligament.  The  infundibulo-pelvic  ligament  connects 
the  outer  end  of  the  Fallopian  tube  to  the  side  wall  of  the  pelvis,  and 
may  be  regarded  as  that  portion  of  the  upper  border  of  the  broad 
ligament  not  occupied  by  the  Fallopian  tube.  It  is  about '2  cm.  in 
length. 

The  ovarian  ligament  extends  from  the  horn  of  the  uterus  to  the 
inner  end  of  the  ovary,  and  is  about  3  cm.  long. 

Histology. — The  ovary  is  covered  with  a  layer  of  nucleated  columnar 
cells,  continuous  at  the  hilum  with  the  peritoneal  endothelium.     At 


MALPOSITIONS  OF  THE  OVARIES 


385 


the  point  of  transition  is  a  white,  glistening  line  called  the  "white 
line  of  Farre."  The  epithelium  covering  the  ovary  is  called  the  "germ 
epithelium  of  Waldeyer,"  and  beneath  it  is  a  fibrous  layer  known  as 
the  tunica  albuginea. 

The  framework  of  the  ovary  is  of  connective  tissue,  and  is  divided 
into  cortical  and  medullary  portions,  the  former  lying  external  to 
the  latter.  The  Graafian  follicles  are  scattered  throughout  the  ovary. 
Nerves,  bloodvessels,  lymphatics,  and  muscular  fibers  are  also  found  in 
the  connective  tissue.  The  medullary  portion  is  more  vascular  than 
the  cortex. 

The  Graafian  follicles  number  40,000  to  70,000  in  the  infant  ovary. 
They  vary  in  size  from  y^q-  to  ^t  iiich  '^^  diameter.  The  younger  and 
smaller  follicles  occupy  the  medullary  portion,  and  as  they  grow  larger 
they  are  found  to  occupy  the  cortical  portion.  A  Graafian  follicle 
consists   of: 

Fig.  274 


Fimbria  ovarica. 

Normal  anatomy  of  the  uterine  appendages. 


1.  The  tunica  fibrosa  and  membrana  propria. 

2.  The  membrana  granulosa  and  discus  proligerus. 

3.  The  liquor  folliculi. 

4.  The  ovum  is  surrounded  by  the  discus  proligerus  and  composed  of: 

(a)  Zona  pellucida,  a  homogeneous  external  membrane. 
(6)  Yolk  protoplasm. 

(c)  Germinal  vesicle. 

(d)  Germinal  spot. 

Parovarium  or  Organ  of  Rosenmiiller. — If  the  broad  ligament  be  held 

between  the  light  and  the  observer's  eye,  this  rudimentary  structure 

will  be  seen  enclosed  in  its  folds  in  the  space  between  the  ovary  and 

ampulla   (Fig.   274).     It  consists  of  closed  tubules  lined  with  ciliated 

25 


386  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

epithelium,  which  converge  toward  the  ovary,  and  are  united  by  a 
longitudinal  one. 

Changes  in  the  Position. — The  normal  position  of  the  ovary  is  at 
the  level  of  the  brim  of  the  pelvis,  midway  between  the  horn  of  the 
uterus  and  the  psoas  muscle.  There  is  a  limited  physiological  range  of 
motion  influenced  by  changes  in  the  position  of  the  uterus,  the  filling 
and  emptying  of  the  bladder  and  rectum,  the  respiratory  movements, 
and  changes  in  the  attitude  of  the  patient.  During  pregnancy  the 
ovaries  are  elevated  into  the  abdominal  cavity. 

Pathological  causes  of  misplaced  ovaries  are: 

1.  Displacements  of  the  uterus  and  tubes. 

2.  Inflammatory  lesions  of  the  ovaries,  increasing  the  weight  of 
the  ovaries  and  causing  them  to  fall  to  a  lower  level,  or  adhesions 
about  the  ovary  drawing  the  organ  out  of  place. 

3.  Newgrowths  about  the  ovaries,  crowding  them  out  of  place. 

4.  Increase  in  size,  and  weight  of  the  ovaries  from  abscesses,  hema- 
tomata,  and  tumor  formations,  causing  them  to  prolapse. 

Descensus  Ovarii. — Classification  (Sanger). —  Descensus  Lateralis. — 
In  this  the  ovary  descends  no  farther  than  the  upper  border  of  the 
sacral  ligament. 

Descensus  Posticus. — In  this  the  ovary  descends  below  the  upper 
border  of  the  uterosacral  fold. 

Etiology. — The  causes  of  descensus  ovarii  are: 

1.  Increase  in  the  weight  of  the  ovary  by : 

(a)  Hypertrophy  and  hyperplasia. 
(6)  Congestion. 

(c)  Hematoma  or  abscess. 

(d)  New-formations. 

2.  Relaxation  of  the  supporting  ligaments  of  the  ovary. 

3.  Retropositions  and  prolapsus  uteri. 

4.  Pelvic  adhesions  pulling  upon  the  ovaries. 

5.  Pelvic  and  abdominal  tumors  pushing  the  ovaries  downward. 

6.  Severe  falls. 

In  4000  cases  Martin  found  the  ovary  descended  in  564,  and  of  this 
number  a  single  ovary  was  prolapsed  86  times.  The  greatest  number 
were  found  between  the  ages  of  twenty-five  and  thirty.  They  are 
rarely  seen  after  fifty  years  of  age. 

A  prolapsed  ovary  rarely  remains  normal.  The  dependent  position 
interferes  with  the  return  circulation,  and  this  leads  to  a  chronic  hyper- 
plasia of  the  ovary  (chronic  ovaritis).  In  the  564  cases  reported  by 
Martin,  chronic  ovaritis  was  found  401  times.  In  15  cases  there  was 
cystic  degeneration  of  the  ovary,  and  in  154  cases  there  was  periovaritis 
with  fixation  from  adhesions. 

Diagnosis. — The  diagnosis  is  based  altogether  upon  the  physical 
findings.  The  symptoms  are  wholly  unreliable  in  identifying  the  lesion. 
Excessive  symptoms  occurred  only  26  times  in  the  564  cases  of  Martin. 
Painful  menstruation,  dyspareunia,  and  pain  in  defecation  are  those 
commonly  present,  though  they  are  by  no  means  constant.    How  much 


MALPOSITIONS  OF  THE  OVARIES  387 

parametritis  and  other  complicating  lesions  have  to  do  with  these 
symptoms  cannot  be  determined.  Sterility  does  not  necessarily  follow. 
It  is  difficult,  if  not  impossible,  to  demonstrate  that  the  reflex  symp- 
toms, such  as  headache  and  dyspepsia,  are  dependent  upon  diseases 
of  the  ovary. 

The  displaced  ovary  is  recognized  by  its  size,  form,  consistency, 
and  sensitiveness  to  pressure.  An  anesthetic  is  always  of  advantage 
and  may  be  indispensable.  A  recto-abdominal  examination  is  often 
more  satisfactory  than  a  vagino-abdominal. 

Not  only  must  the  position  of  the  ovary  be  located,  but  it  is  neces- 
sary that  the  cause  of  the  displacement  be  ascertained. 

Treatment. — Not  all  prolapsed  ovaries  require  treatment.  The  condi- 
tion commonly  exists  with  no  discornfort,  and  in  such  cases  no  treat- 
ment is  advised  and  the  patient's  attention  should  not  be  called  to  the 
condition.  When,  however,  the  abdomen  is  opened  for  the  correction 
of  other  lesions,  and  one  or  both  ovaries  are  found  to  be  prolapsed,  the 
ovary  should  be  restored  to  its  normal  position  by  operative  means. 

Palliative  Treatment. — When  the  ovary  is  congested  as  the  result  of 
the  displacement,  some  relief  may  be  afforded  by  the  enforcement  of 
rest,  hot  vaginal  douches,  sitz  baths,  glycerin  and  ichthyol  tampons, 
and  the  careful  regulation  of  the  bowels.  The  application  of  these 
tentative  measures  is  similar  to  that  in  the  conservative  treatment  of 
pelvic  inflammation.  (See  page  435.)  It  is  useless  to  attempt  to  hold 
the  ovary  in  place  by  pessaries  or  tampons,  or  to  restore  the  ovary  to 
its  normal  position  by  means  other  than  surgical. 

Radical  Treatment.- — When  palliative  measures  fail  to  give  relief, 
resort  must  be  had  to  surgery. 

When  the  ovaries  are  prolapsed,  together  with  a  backward  or  down- 
ward displacement  of  the  uterus,  the  author  favors  the  retro-uterine 
looping  of  the  round  ligaments  (Webster-Baldy).  In  this  operation 
the  round  ligaments  are  brought  through  the  broad  ligaments  at  a 
point  below  the  ovarian  ligament.  In  this  manner  the  ovaries  are 
elevated. 

When  the  uterus  is  not  displaced  backward  or  downward,  one  of  two 
procedures  may  be  adopted:  (1)  The  infundibulopelvic  ligament  may 
be  shortened  by  taking  a  reef  in  it  with  two  fine  linen  sutures,  and,  if 
necessary,  similar  sutures  may  be  passed  through  the  ovarian  ligament. 
The  objection  to  this  procedure  is  that  the  ovarian  veins  may,  in  this 
way,  be  kinked  and  lead  to  passive  congestion  of  the  ovaries.  The 
author  has  not  observed  this.  (2)  A  button-hole  may  be  made  through 
the  broad  ligament  at  a  point  immediately  below  the  hilum  of  the 
ovary,  and  the  ovary  brought  through  this  opening  on  to  the  anterior 
surface  of  the  broad  ligament.  Sutures  may  be  passed  at  either  extrem- 
ity of  this  incision  so  as  to  partially  close  the  opening,  but  not  to  con- 
strict the  blood  supply  to  the  ovary.  It  is  said  that  the  ovary  in  this 
position  does  not  lessen  the  chances  of  conception.  The  author  has 
done  this  operation  in  a  number  of  instances  when  the  ovary  had  been 
adherent  and  it  was  desired  to  prevent  the  reformation  of  adhesions 


388  MALPOSITIONS  OF  THE  GENITAL  ORGANS 

to  the  bowel- — an  event  that  would  be  more  liable  to  ensue  with  the 
ovary  lying  posterior  to  the  broad  ligament  than  anterior. 

Resection  of  the  ovary  should  be  done  when  a  part,  but  not  all,  of 
the  ovary  is  diseased.  All  healthy  portions  of  the  ovary  should  be 
conserved  and  the  resected  portion  placed  in  the  normal  position  as 
above  suggested.  Removal  of  the  ovary  is  done  for  prolapsus  only 
when  the  entire  ovary  is  diseased;  the  occasion  will  rarely  arise. 

Hernia  of  the  Tube  and  Ovary. — The  Fallopian  tube  and  ovary  or 
a  part  or  all  of  either  organ  may  be  herniated.  These  structures  may 
lie  alone  in  the  hernial  sac,  or  may  be  associated  with  the  uterus, 
appendix,  coil  of  bowel,  bladder,  ]Meckers  diverticulum,  or  omentum. 

The  lesion  may  be  congenital  or  accpiired,  and  may  be  unilateral 
or  bilateral.  It  may  develop  at  any  period  in  the  life  of  women,  no 
age  being  exempt. 

These  hernias  are  classified  as  postoperative,  inguinal,  femoral, 
gluteal,  obturative,  ventral,  and  ischiadic,  according  to  their  point 
of  exit.     The  most  common  variety  is  the  inguinal. 

As  with  other  hernias  we  find  them  inflamed,  strangulated,  reducible, 
and  incarcerated.    Torsion  of  the  pedicle  is  a  possibility. 

Such  hernias  do  not  of  necessity  prevent  conception,  or  interfere 
with  the  development  and  completion  of  pregnancy,  unless  associated 
with  anomalous  developments  of  the  genitalia.  The  etiology  of  this 
variety  of  hernia  is  the  etiology  of  hernia  in  general,  i.  e.,  increased 
intra-abdominal  pressure  and  a  weakening  of  the  abdominal  wall,  either 
as  an  acquired  or  as  a  congenital  defect.  The  herniated  organs  may 
be  normal  or  may  be  the  seat  of  any  of  the  diseases  otherwise  found  in 
the  appendages  and  other  structures  found  in  the  hernia  sac.  These 
pathological  changes  may  precede  or  follow  the  development  of  the 
hernia. 

Treatment. — Spontaneous  cure  is  known,  but  is  rare,  and  can  only 
follow  upon  the  reduction  of  the  hernia.  The  rational  treatment  con- 
sists in  a  radical  operation.  Early  operation  is  the  most  satisfactory 
treatment.  If  the  tube  and  ovary  are  normal,  they  are  to  be  returned 
to  the  pelvic  cavity;  if  diseased,  they  are  to  be  dealt  with  either  by 
resection  or  removal  according  to  the  conditions  found. 


CHAPTER  XVII 

CIRCULATORY  DISTURBANCES  AND  INFLAMMATIONS 
OF  THE  GENITAL  ORGANS 

Bacteriology  of  the  NoRaL*LL  Geni-  Etiology 

TAL  Tract  General  causes 

i  Local  causes 

The  various  circulatory  disturbances  and  inflammations  of  the  geni- 
talia are  so  intimately  associated  from  both  the  anatomical  and  clinical 
standpoints  as  to  justify  the  grouping  of  the  various  lesions  which 
they  present.  By  so  doing  the  student  will  better  understand  the 
intimate  relation  which  these  diseases  bear  to  one  another.  They  are 
so  closely  associated  and  so  constantly  complicate  one  another,  that 
all  the  associated  lesions  must  be  considered  if  one  is  to  be  successful 
in  the  management;  of  this  class  of  cases. 

An  infection  begins  in  the  cervical  mucosa  and  endometrium,  but  it 
rarely  remains  confined  to  these  structures,  and  is  conveyed  downward 
to  the  vagina  and  vulva,  and  upward  and  outward  to  the  myometrium, 
tubes,  ovaries,  peritoneum,  and  pelvic  cellular  tissue.  A  comprehensive 
view,  therefore,  must  be  taken  of  the  clinical  picture  in  its  entirety. 

Pelvic  inflammations  constitute  a  large  proportion  of  the  diseases 
peculiar  to  women,  and  are  responsible,  in  no  small  degree,  for  invalidism 
and  death. 

Bacteriology  of  the  Normal  Genital  Tract. — The  bacteriology  of 
the  normal  genital  tract  has  been  a  subject  of  controversy  from  the 
beginning  of  bacteriological  research,  and  is  still  a  debatable  question. 
Observers  agree  that  no  micro5rganisms  are  to  be  found  under  normal 
conditions  above  the  external  os.  That  they  exist  in  large  numbers 
and  in  great  variety  in  the  vagina  and  at  the  vulva  is  conceded  by  all, 
but  to  what  extent  these  microorganisms  are  pathogenic  is  an  unsettled 
question.  The  consensus  of  opinion  among  the  highest  authorities, 
such  as  Ejonig,  ^Nlenge,  and  Williams,  is,  that  while  pathogenic  micro- 
organisms may  be  found  in  the  healthy  vulva  and  vagina,  they  cannot 
long  exist  and  still  earlier  lose  their  virulence.  But  under  abnormal 
conditions,  such  as  congestion  and  trauma  and  when  conveyed  to  the 
upper  genital  organs,  these  same  microorganisms  may  become  virulent. 
The  importance  of  these  observations  is  obvious,  for  with  an  unob- 
structed passageway  from  the  vulva  to  the  vagina,  thence  to  the  cavity 
of  the  uterus,  tubes,  and  free  pelvic  and  abdominal  cavity,  there  would 
be  constant  danger  to  health  and  life  were  it  not  for  the  safeguards 
which  nature  has  provided. 


390     CIRCULATORY  DISTURBANCES  OF  THE  GENITAL   ORGANS 

Etiology. — Frequency. — Genital  infections  and  circulatory  disturb- 
ances in  women  owe  their  frequency  to  certain  anatomical  and  physio- 
logical peculiarities.  There  is  an  unobstructed  passageway  leading 
from  without  to  the  peritoneal  cavity  by  which  infection  may  travel; 
the  periodic  congestion  of  the  pelvic  structures,  which  recurs  at  each 
monthly  period  during  menstruation  and  prevails  throughout  pregnancy 
and  the  puerperium,  renders  these  tissues  peculiarly  susceptible  to 
infection,  and  the  traumata  incident  to  labor  provide  avenues  through 
which  infection  is  conveyed  to  the  deeper  structures,  and  to  remote 
parts  of  the  body.  Furthermore,  the  mobility  of  the  uterus  and  its 
appendages  readily  leads  to  faulty  positions,  with  resultant  circulatory 
disturbances.  "Women,  through  faulty  dress,  careless  management  of 
the  diet,  irregularity  of  the  bowels  and  excessive  exercise,  are  particu- 
larly prone  to  acquire  pelvic  congestion. 

At  no  time  in  the  history  of  women,  from  their  prenatal  stage  to 
old  age,  is  the  genital  tract  immune  to  infection.  The  time  when  the 
genital  organs  are  most  susceptible  to  the  invasion  of  microorganisms 
and  to  circulatory  disturbance  is  the  period  of  sexual  maturity,  when 
the  tissues  are  at  the  acme  of  their  functional  activity  and  are  most 
subject  to  injury. 

Barriers  to  Infection. — Certain  natural  barriers  exist  in  tiie  genital 
tract,  as  safeguards  against  the  invasion  of  microorganisms.  In  infancy 
the  hymen  presents  an  effective  barrier  to  the  advance  of  microorgan- 
isms, as  do  also  the  small  cervical  canal  and  the  tortuous  Fallopian 
tubes,  with  their  small  lumena.  Finally,  the  underdeveloped  lymph  and 
blood  channels,  leading  through  and  from  the  genital  organs,  have  a 
limited  capacity  for  conveying  infection.  At  this  period  in  life  pelvic 
inflammations  and  circulatory  disturbances  are  not  common,  and 
when  they  do  exist  are  usually  confined  to  the  vidya  and  vagina. 

In  old  age  the  atrophic  changes  which  occur  in  the  genital  organs 
and  lead  to  partial  or  complete  obliteration  of  the  uterine  canal  and 
Fallopian  tubes,  together  with  narrowing  of  the  lymph  and  blood 
channels,  render  the  upper  genital  tract  all  but  immune  to  infection. 

There  is  at  all  times,  and  particularly  in  the  period  of  sexual  maturity, 
a  germicidal  action  on  the  part  of  the  vaginal  secretions.  These  secre- 
tions are  acid  in  reaction,  and  none  of  the  pathogenic  germs  which  attack 
the  genital  tissues  can  thrive  in  an  acid  medium.  Furthermore,  the 
many  layers  of  squamous  epithelium  which  cover  the  surfaces  of  the 
vulva,  vagina,  and  vaginal  portion  of  the  cervix  effectively  resist  the 
direct  invasion  of  microorganisms.  In  infancy  this  epithelial  covering 
is  delicate  and  in  old  age  it  is  devitalized;  hence  it  follows  that  vulvo- 
vaginitis is  relatively  frequent  in  the  extremes  of  life,  and  is  not  of 
common  occurrence  as  a  primary  lesion  in  middle  age. 

General  (Constitutionalj  Causes. — Circulatory  disturbances  and  inflam- 
mations of  the  genital  organs  are  not  infrequently  influenced  by  condi- 
tions which  lie  remote  from  the  pelvis.  Failure  to  appreciate  this  fact 
leads  to  failure  in  the  management  of  these  cases.  Following  are  the 
chief  constitutional  factors: 


ETIOLOGY  391 

1.  Gout. 

2.  Ptiieimiatism. 

3.  Litliemia.. 

4.  Anemia  (particularly  chlorosis). 

5.  Tuberculosis. 

6.  Incompetent  heart. 

7.  Diseases  of  the  lungs,  liver,  kidney  and  spleen,  leading  to  pelvic 

congestion. 

8.  Acute  infectious  diseases. 

9.  General  lowered  resistance. 

Local  Causes. — 1.     Infections  following  labor  and  abortion. 

2.  Gonorrhea. 

3.  Instrumental  and  digital  infections. 

4.  Foreign  bodies  (including  tumors). 

5.  Extension  from  surrounding  structures. 

6.  Mechanical  disturbances. 

-     7.  Displacements  of  the  genital  organs. 

8.  Subinvolution  of  the  uterus. 

9.  Exposure  to  cold. 

10.  Waist  constriction. 

11.  Constipation. 

1.  Infections  following  Labor  and  Abortion. — Puerperal  infection 
is  essentially  a  wound  infection.  In  every  case  of  labor  there  is  a 
necessary  wound:  always  at  the  placental  site,  usually  in  the  cervix, 
and  commonly  in  the  vagina,  vulva,  and  perineum.  Exposed  to  infection 
by  pathogenic  microorganisms,  through  the  incidents  of  labor  and  the 
puerperium,  there  is  a  condition  in  puerperal  sepsis  which  engages  our 
serious  consideration  because  of  its  frequency  and  its  effect  upon  the 
health  and  life  of  women.  "VMiile  the  infection  usually  has  its  inception 
at  the  placental  site  or  in  wounds  located  below  this  point,  it  rarely 
remains  localized  at  the  point  of  infection,  but  is  conveyed  to  adjacent 
and  remote  fields.  Hence  it  follows  that  pelvic  inflammation  of  puer- 
peral origin  commonly  presents  a  group  of  inflammatory  lesions  rather 
than  a  single  isolated  lesion. 

2.  Gonorrhea. — -The  section  in  Hygiene  and  Sanitary  Science  of  the 
American  Medical  Association  in  1901  reported  that  in  the  experience 
of  many  European  and  American  gjTiecologists,  40  per  cent,  of  women 
suffering  from  pelvic  inflammation  have  gonorrhea.  Wolbarst  makes 
the  startling  statement  that  70  per  cent,  of  married  women  who  com- 
plain of  pelvic  disorders  have  acquired  gonorrhea  innocently  from 
their  husbands. 

The  fact  must  not  be  oA'erlooked  that  at  least  14  per  cent,  of  puerperal 
infections  are  due  to  the  gonococcus.  The  gonococcus  in  these  cases 
is  either  introduced  during  pregnancy,  labor,  or  the  puerperium,  or 
it  has  lain  dormant  in  the  uterus  and  its  appendages  throughout  the 
course  of  pregnancy,  to  be  awakened  to  renewed  activity  by  the  con- 
gestion and  trauma  of  pregnancy  and  labor.     These  facts  emphasize 


392      CIRCULATORY  DISTURBANCES  OF  THE  GENITAL  ORGANS 

the  importance  of  seriously  considering  latent  gonorrheal  infections, 
and  particularly  so  when  associated  with  pregnancy. 

3.  iTistrumental  and  Digital  Injections. — Failure  to  sterilize  instru- 
ments used  in  examinations  and  operations  is  often  responsible  for 
infection.  This  is  true  of  the  examining  finger  as  well.  Gonorrheal 
infections  may  be  conveyed  by  the  speculum  and  the  sound  through 
failure  on  the  part  of  the  physician  to  properly  cleanse  his  instruments. 
In  this  connection  attention  is  directed  to  the  pernicious  habit  of 
exploring  and  making  topical  applications  to  the  interior  of  the  cervix 
and  uterus  in  office  practice,  where  there  is  not  adequate  protection 
against  infection. 

4.  Foreign  Bodies,  Including  Tumors. — Tampons  and  pessaries  left 
an  undue  time  within  the  vagina  will  create  an  inflammatory  reaction, 
leading  to  erosions,  ulcerations,  and  cicatrization  of  the  vagina  and 
cervix.  Likewise,  stem  pessaries  create  irritation  of  the  cervix.  Tumor 
formations,  wherever  located  in  the  pelvis,  are  not  infrequently  the 
cause  of  adhesions  brought  about  through  mechanical  irritation. 

5.  Extension  from  Surrounding  Structures. — -The  tendency  of  all 
infections  is  to  spread  to  adjacent  structures.  It  follows  that  we,  as 
a  rule,  have  to  do  with  a  combination  of  inflammatory  lesions  in  the 
pelvic  organs. 

6.  Mechanical  Disturbances. — Circulatory  disturbances  and  inflam- 
mations are  the  result  of  such  mechanical  disturbances  as  excessive 
venery,  running  a  sewing  machine,  and  horseback-riding. 

7.  Displacements  of  the  Genital  Organs. — Displacements  of  a  marked 
degree  are  associated  with  passive  congestion  of  the  displaced  organ, 
and  this  congestion,  in  turn,  predisposes  to  infection. 

8.  Subinwlution  of  the  Uterus. — -Subinvolution  of  the  uterus  may 
be  the  beginning  of  a  series  of  organic  and  functional  disturbances, 
prominent  among  which  are  the  menstrual  irregularities  based  upon  a 
congested  uterus. 

9.  Exposure  to  Cold. — Pelvic  congestion  may  result  from  exposure  at 
the  menstrual  period,  and  is  the  forerunner  of  menstrual  disorders. 

10.  Waist  Constriction. — See  page  241. 

11.  Constipation. — The  habit  of  constipation  is  almost  universal 
in  women,  and  is  responsible  for  many  of  the  circulatory  disturbances 
in  the  pelvis. 


CHAPTER   XVIII 

CIRCULATORY  DISTURBANCES  AND  INFLAMMATIONS 
OF  THE  VULVA  AND  VAGINA 


Circulatory  Disturbances  of  the 
Vulva 
Varicose  Veins  (Angioma   Vulvae, 
Hematoma  of  the  Vulva 
Edema  of  the  Vulva 
Gangrene  of  the  Vulva 
Noma  Pudendi 
Inflammation  of  the  Vulva — 
Vulvitis 

Simple  Catarrhal 

Gonorrheal 

Erysipelatous 

Vulvitis  Furunculosis 

Puerperal 

Tuberculous 


Syphilitic 

Actinomycosis 

Treatment 
Bartholinitis 
Pruritus  Vulvae 
Inflammation  of  the  Vagina 
Vaginitis  (Colpitis) 

Catarrhal 

Ulcerative 

Tuberculous 

Emphysema  Vaginae 

Senile 
Paravaginitis 
Vaginismus- 


CIRCULATORY  DISTURBANCES  IN  THE  VULVA 


Varicose  Veins  (Angioma  Vulvae). — In  varicose  veins  of  the  vulva 
the  veins  are  tortuous,  knotty,  and  irregularly  dilated.  This  condition 
may  involve  one  or  both  labia  majora. 

Etiology. — The  most  prominent  etiological  factor  is  pregnancy. 

1.  Pregnancy. — Pregnancy  is  always  associated  with  venous  con- 
gestion in  the  pelvis.  If,  as  a  result  of  incarceration  of  the  pregnant 
uterus  or  complicating  tumors,  the  return  circulation  is  retarded,  the 
veins  of  the  vulva,  as  well  as  those  of  the  pelvis,  become  overdistended. 

2.  Miscellaneous  Causes. — Miscellaneous  causes,  such  as  heavy 
lifting,  long-standing  pelvic  tumors,  uterine  displacements,  and  pelvic 
exudates  operate  in  producing  varicosities  of  the  vulva. 

Symptoms. — A  moderate  distention  of  the  veins  may  give  rise  to 
no  inconvenience,  but  prominent  veins  which  enlarge  the  vulva  cause 
a  feeling  of  heaviness,  irritation,  and  itching.  Locomotion  and  inter- 
course may  be  embarrassed. 

Diagnosis. — On  inspection  an  irregular,  elongated,  knotty  mass  is 
seen  to  occupy  one  or  both  labia  majora,  more  rarely  other  vulvar 
structures  and  the  vaginal  walls  are  affected.  The  color  is  a  deep 
blue.  On  palpation  the  prominent  veins  are  made  to  disappear  unless 
excessively  enlarged.  While  rarely  attaining  a  size  greater  than  a  hen's 
egg,  they  have  reached  the  size  of  a  child's  head. 


394     CIRCULATORY  DISTURBANCES  OF  VULVA  AND  VAGINA 

Prognosis. — When  occurring  for  the  first  time  in  pregnancy  the 
swelHng  is  greatly  reduced  in  size  shortly  after  childbirth  and  may 
wholly  disappear,  but  with  each  succeeding  pregnancy  the  condition 
becomes  permanent  and  larger.  The  veins  may  rupture  and  give  rise 
to  a  hematoma  or  to  external  hemorrhage  of  alarming  proportions. 
Again,  thrombosis  of  the  veins  may  lead  to  embolism  that  may  prove 
fatal. 

Treatment. — Unless  the  mass  gives  rise  to  serious  disturbances  or  is 
very  large,  palliative  measures  will  suffice. 


Fig.  276 


Varicocele  of  the  vulva.     A  median  incision  in 
the  labium  exposes  the  dilated  veins. 


The  veins  are  ligated  with  catgut  at  either 
extremity  and  the  overlying  incision  in  the  skin 
is  closed  with  a  running  horse-hair  suture. 


Palliative  Treatment. — When  arising  in  the  course  of  pregnancy  an 
abdominal  binder  should  be  worn,  together  with  a  gauze  vulvar  pad, 
supported  by  a  T-binder.  This  combination  gives  support^  to  the 
uterus  and  distended  veins.  All  waist  constriction  must  be  removed 
and  straining  and  heavy  exertion  of  all  kinds  avoided.  When  the 
condition  causes  much  distress  the  patient  should  be  enjoined  to  rest 
in  the  recumbent  position  more  or  less  of  the  time.  To  relieve  the 
sensation  of  itching  and  burning,  a  compress  of  cold  water  or  of  lead 
water  and  laudanum  should  be  applied  to  the  vulva.     The  patient 


CIRCULATORY  DISTURBAXCES  IN   THE  VULVA 


395 


should  be  instructed  in  event  of  hemorrhage  to  tightly  compress  the 
bleeding  veins  until  surgical  aid  is  secured. 

Operative  Treatment.— When  the  s^^nptoms  cannot  be  relieved  by 
conservative  measures  it  becomes  imperative  to  ligate  and  remove 
the  veins.  The  accompanying  diagrams  (Figs.  275  and  276)  illustrate 
the  method  of  procedure. 


Fig.  27; 


w 


Rodent  ulcer  of  the  vulva.     (Hertzler.) 


Hematoma  of  the  Vulva. — Hematoma  of  the  A'ulva  may  arise  from 
rupture  of  the  veins  during  labor  or  from  direct  injury.  Such  accu- 
mulations of  blood  may  attain  the  size  of  a  man's  head.  While  suppu- 
ration of  the  blood-clot  may  occur,  gradual  absorption  is  the  rule. 

Treatment. — Failure  of  the  blood-mass  to  absorb,  or  in  event  of 
suppuration  of  the  blood,  an  incision  is  made  for  the  purpose  of  estab- 
lishing drainage.  Every  effort  should  be  made  to  favor  absorption. 
Rest  should  be  enjoined,  and  a  soft,  firm  compress  held  in  place  by  a 
T-bandage  will  usually  hasten  absorption. 


396     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

Edema  of  the  Vulva. — Edema  of  the  vulva  may  arise  from  an  obstruc- 
tion to  the  general  circulation  in  diseases  of  the  heart,  kidney,  liver, 
etc.,  but  it  is  more  often  the  result  of  local  interference  with  the  cir- 
culation from  pressure  of  the  pregnant  uterus,  pelvic  tumors,  and 
exudates.  The  swelling  may  be  bilateral  or  confined  to  one  side,  and 
may  be  as  large  as  a  child's  head. 

Symptoms. — Moderate  edema  gives  rise  to  no  symptoms,  but  the 
swelling  may  be  so  large  as  to  interfere  Avith  walking,  sexual  inter- 
course, and  even  with  urinating.  This  exaggerated  form  is  usually 
associated  with  general  anasarca. 

Fig.  278 


Rodent  ulcer  of  the  vulva.     (Hertzler.) 


Prognosis. — The  prognosis  is  dependent  upon  the  underlying  cause. 
When  associated  with  general  anasarca  the  outlook  is  grave.  And 
when  it  is  a  phase  of  angioneurotic  edema  the  prospect  of  cure  is  not 
encouraging. 

Treatment. — The  essential  element  in  treatment  is  to  remove,  if 
possible,  the  cause.  The  condition  may  be  palliated  by  a  compress  of 
lead  water  and  laudanum.  Scarification  of  the  swollen  vulva  is  indicated 
when  there  is  great  tension. 

Gangrene  of  the  Vulva. — Gangrene  of  the  vulva  is  a  rare  but  grave 
condition. 


INFLAMMATIONS  OF  THE  VULVA  397 

Etiology. —  Trauma. — A  direct  blow  or  the  falling  astride  of  an  object 
may  result  in  death  of  the  bulbar  tissue.  More  often  the  trauma  is 
received  in  pregnancy  and  in  labor,  and  is  usually  preceded  by  a  hema- 
toma or  edema  of  the  vulva. 

Infectious  Diseases. — Infectious  diseases,  such  as  puerperal  sepsis, 
erysipelas,  typhoid  fever,  diphtheria,  measles,  scarlet  fever,  and  small- 
pox, are  occasional  causes. 

Noma  Pudendi. — Noma  pudendi  is  a  peculiar  local  infection  resulting 
in  death  of  the  tissues.  The  disease  is  commonly  known  as  rodent 
ulcer. 

Symptoms. — The  labium  ma  jus  of  one  side  is  the  site  of  predilection. 
In  the  beginning,  there  is  a  tender,  reddened  zone  which  deepens  in 
color  and  finally  becomes  black,  with  a  red  zone  surrounding  the 
gangrenous  area.  Vesicles  and  bullae  appear,  and  later  the  tissue 
sloughs  away,  exposing  a  weeping  surface. 

Prognosis. — The  prognosis  is  grave  in  this  condition;  septicemia, 
embolism,  and  exhaustion  are  the  causes  of  death.  When  there  is 
septic  absorption,  alcoholic  stimulants  and  a  nutritious  liquid  diet 
should  be  given  freely. 

Treatment. — In  gangrene  of  the  vulva,  including  noma  pudendi,  all 
dead  tissue  should  be  excised  and  the  wound  frequently  irrigated. 
Warm  antiseptic  fomentations  should  be  applied  and  renewed  at  short 
intervals.  For  this  purpose  a  sterile  gauze  pad,  saturated  with  a  solu- 
tion of  formalin  1  part,  glycerin  400  parts,  and  sterile  water  2000  parts, 
should  be  used.  Over  this  a  covering  of  rubber  protective  should  be 
placed,  and  held  by  a  T-bandage. 

The  thermocautery  may  be  effectively  used  from  time  to  time,  and 
is  especially  serviceable  when  the  gangrenous  area  is  large. 

INFLAMMATIONS  OF  THE  VULVA 

Vulvitis. — Simple  Catarrhal  Vulvitis. — Simple  catarrhal  vulvitis  is 
commonly  found  in  the  acute  stage,  rarely  in  the  chronic  stage. 

1.  Acute  Catarrhal  Vulvitis. — Acute  catarrhal  vulvitis  presents  a 
surface  that  is  swollen,  red,  and  glistening.  Later  there  is  a  muco- 
purulent secretion  on  the  vulvar  surface.  Part  or  all  of  the  vulvar 
structures  may  be  enlarged,  but  it  is  unusual  for  the  disease  to  extend 
into  the  upper  genital  tract,  as  is  the  case  with  gonorrheal  vulvitis. 

2.  Chronic  Catarrhal  Vulvitis. — In  the  chronic  stage  the  swelling 
subsides  and  the  redness  largely  disappears.  The  secretion  is  less 
abundant,  but  remains  of  a  mucopurulent  character.  Abrasions  and 
ulcerations  are  seen  on  the  vulvar  surface,  and  the  inguinal  glands  may 
enlarge. 

Symptoms. — In  the  acute  stage  the  patient  complains  of  pain  and 
tenderness  in  the  affected  area;  the  urine  coming  in  contact  with  the 
inflamed  vulva  causes  smarting  and  burning;  walking  is  uncomfortable, 
and  the  skin  surface  on  the  inner  aspect  of  the  thigh  and  anal  region 
becomes  irritated  from  the  secretions.     In  the  chronic  stage,  itching 


398     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

and  burning  are  complained  of.  The  discomfort  may  be  so  great  that 
the  patient  finds  Hfe  intolerable. 

Diagnosis. — It  is  essential  to  recognize  this  form  of  vulvitis  from  the 
gonorrheal  form.  An  innocent  individual  may  acquire  a  gonorrheal 
infection,  hence  the  unreliability  of  the  history'-  in  many  cases.  The 
infallible  test  is  found  in  the  microscopic  examination  of  the  secretions. 
The  presence  of  pus  in  the  urethra,  of  an  involvement  of  the  glands  of 
Bartholin,  and  of  the  inguinal  glands  are  presumptive  but  not  con- 
clusive evidences  of  the  gonorrheal  nature  of  the  infection. 

Gonorrheal  Vulvitis.— This  subject  is  presented  in  Chapter  XXIII. 

Erysipelatous  Vulvitis. — Erysipelas  of  the  vulva  is  occasionally 
observed  in  the  puerperium  and  in  the  newborn.  Recurrent  attacks 
have  been  experienced.  The  infection  is  liable  to  become  active  at 
the  menstrual  period.  The  essential  cause  is  the  streptococcus  of 
erysipelas.  Predisposing  factors  are  puerperal  wounds,  erosions, 
ulcers,  abrasions  of  the  vulva,  unsanitary  surroundings,  and  lowered 
general  vitality. 

Symptoms. — The  disease  is  usually  ushered  in  by  a  chill,  elevation 
of  temperature,  and  vomiting.  The  temperature  ranges  from  100° 
to  105.5°,  and  will  usually  persist  throughout  the  course  of  the  disease. 
In  severe  cases  general  toxic  symptoms  are  present.  The  pulse  is 
quickened,  and  there  is  headache,  drowsiness,  and  possibly  delirium. 

The  eruption  usually  begins  as  a  single  patch  upon  the  vulvar  surface, 
which  spreads  with  more  or  less  rapidity  over  the  surface,  and  presents 
a  sharp,  often  indented  border  that  is  raised  above  the  healthy  skin. 
The  color  deepens  to  a  dark  hue,  and  vesicles  and  blebs  may  form. 
These  may  suppurate  and  leak,  leaving  a  dry  crust.  As  the  lesion 
extends,  the  central  area  becomes  flattened  and  pale.  Isolated  patches 
may  appear  in  the  neighborhood  of  the  original  lesion.  The  author  has 
seen  erysipelas  of  the  vuh'a  in  an  infant  extend  upward  through  the 
vagina  and  uterus  to  the  peritoneum.  The  lymphatics  and  lymph 
glands  of  the  groin  are  involved.  The  lymphatics  appear  as  red  streaks 
and  the  glands  may  suppurate. 

The  subjective  symptoms  are  itching,  burning,  tingling,  and  a  feeling 
of  tension. 

Diagnosis. — The  diagnosis  should  be  made  with  little  difficulty. 
Following  a  chill  and  accompanied  by  constitutional  disturbances, 
the  lesion  is  found  upon  the  vulva  as  a  sharply  circumscribed,  swollen 
red  patch  which  advances  steadily  to  the  surrounding  structures. 

Erysipelas  is  to  be  distinguished  from  eczema,  erythema,  and  urticaria. 

In  eczema  the  constitutional  disturbances  are  not  marked,  there 
is  no  swefiing  of  the  tissues,  the  margins  of  the  lesion  fade  into  the 
surrounding  parts,  the  color  is  not  so  brilliant,  and  the  surface  is  rougher 
and  more  scaly.    Itching  is  more  intense. 

In  erythema  there  are  no  constitutional  symptoms,  the  color  dis- 
appears on  pressiu-e,  and  springs  back  promptly  when  the  pressure 
is  removed.  The  lesion  does  not  creep  over  surrounding  structures, 
and  the  duration  of  the  lesion  is  short. 


INFLAMMATIONS  OF  THE  VULVA  399 

In  urticaria  there  are  no  constitutional  symptoms  and  no  tenderness, 
but  there  is  great  itching,  a  short  course,  and  the  presence  of  wheals 
or  a  history  of  them. 

Treatment. — There  is  no  specific  treatment  for  erysipelas.  The 
tincture  of  chloride  of  iron  in  20  to  60  minim  doses  should  be  given 
every  two  to  four  hours.  The  local  treatment  is  of  great  importance. 
The  lead  and  opium  wash  has  long  been  used,  and  is  prescribed  as 
follows : 

I^ — Liq.  plumbi  subacetat.  dil. 5i -iij 

Tinct.  opii 3ij-iv 

Aquse q.  s.  ad  Oj 

Sig. — Apply  locally. 

Ichthyol  in  a  25  to  50  per  cent,  solution  is  a  splendid  application. 
Painting  the  surface  with  tincture  of  iodine,  diluted  with  equal  parts 
of  alcohol,  is  recommended. 

Puerperal '  Vulvitis. — Puerperal  vulvitis  occurs  as  the  result  of  an 
irritating  lochial  discharge.  A  diffuse  erythema  and  ulceration  may 
arise.  The  ulcers  are  usually  superficial,  with  a  gray  or  brownish  colored 
base  and  an  infiltrated  margin.  A  false  membrane  may  cover  the 
ulcerated  surface,  suggesting  in  appearance  a  diphtheritic  ulcer.  The 
organism  commonly  found  in  these  ulcers  is  the  streptococcus.  Very 
rarely  the  Klebs-Loeffler  bacillus  is  obtained. 

Tuberculous  Vulvitis. — Tuberculous  vulvitis  is  a  rare  lesion.  Irregu- 
lar ulcerations  are  found  at  any  point  in  the  external  genitals.  These 
ulcers  have  a  ragged,  undermined  margin,  with  an  irregular  base 
covered  with  pus  and  studded  with  grayish  tuberclse.  Fistulas  may 
lead  to  the  bowel.  Extensive  cicatrization,  causing  deformity  of  the 
vulva,  may  follow  the  ulceration.  The  tubercle  bacillus  is  difficult  of 
demonstration  in  the  secretion.  A  section  taken  from  the  involved 
structures  may  show  giant  cells  and  tubercles,  more  rarely  the  tubercle 
bacillus. 

Syphilitic  Vulvitis. — Syphilitic  vulvitis  occurs  in  the  primary,  second- 
ary, and  tertiary  stages.  In  the  primary  stage  the  chancre  may  be 
found  at  any  point  on  the  vulva.  The  extent  of  the  lesion  varies  in 
proportion  to  the  associated  edema  and  cellular  infiltration,  the  greatest 
swelling  occurring  in  the  labia  majora,  where  the  cellular  tissue  is 
loosest  and  most  abundant.  In  the  secondary  stage  the  vulva  is  often 
covered  with  condylomata,  which  early  ulcerate  and  are  covered  with 
a  slimy  secretion  of  a  highly  infectious  nature.  In  the  tertiary  stage 
gummata  are  rarely  found. 

The  so-called  soft  chancre  (ulcus  molle)  has  its  favorite  seat  in  the 
frenulum  and  labia  minora.  The  ulcer  formed  from  the  soft  chancre 
is  round,  with  a  sharp  border  and  a  smooth  base  covered  with  pus. 
In  the  neighborhood  of  the  ulcer  the  vessels  are  markedly  dilated. 

Diphtheritic  Vulvitis. — True  diphtheria  may  attack  the  vulvar 
surface.  The  author  has  seen  but  one  such  case.  The  nurse  in 
attendance  had  a  diphtheritic  infection  in  the  throat  and  the  patient 
was  in  the  early  puerperium.     The  patient  responded  to  antitoxin. 


400     CIRCULATORY  DISTURBANCES  OF  VULVA  AND  VAGINA 

Actinomycosis  of  the  Labia  Majora. — Actinomycosis  of  the  labia 
majora  has  been  observed  once  by  Lieblenis  and  again  by  Bongartz. 

Treatment  of  Vulvitis. — Whatever  the  cause  of  the  inflammation 
the  treatment  must  be  based  upon  two  essential  principles :  the  removal 
of  the  cause  and  the  maintenance  of  rest  and  cleanliness.  Failing  in 
these  essential  principles,  recovery  will  be  slow  and  uncertain. 

Acute  Stage — Throughout  the  acute  stage  of  vulvitis  rest  in  bed  is 
imperative.  Antiseptic  vaginal  douches  should  be  given  every  four  to 
six  hours,  and  these  should  be  ten  minutes  in  duration  and  at  a  tem- 
perature of  110°  F.  The  author's  preference  is  for  formalin  douches, 
1  to  2000.  When  due  to  gonorrheal  infection,  the  infected  surface 
should  be  subjected  to  an  application  of  25  per  cent,  aqueous  solution 
of  argyrol.  This  is  best  done  by  loosely  packing  the  vulvar  orifice, 
and  if  possible,  the  vagina,  with  sterile  gauze  or  absorbent  cotton, 
saturated  with  this  solution.  These  tampons  are  to  be  removed  in 
four  to  six  hours.  When  the  acute  stage  subsides,  a  4  per  cent,  solution 
of  silver  nitrate  is  applied  twice  weekly  to  the  infected  surface,  and 
formalin  douches  are  continued  morning  and  evening.  To  allay  irri- 
tation of  the  surrounding  surfaces,  the  douches  should  be  followed  by 
the  application  of  oxide  of  zinc  ointment,  bismuth,  calomel,  talcum, 
or  lycopodium,  after  which  a  sterile  vulvar  pad  is  applied  and  held  in 
place  by  a  T-binder.  If  the  urine  is  acid  and  irritating,  large  quantities 
of  water  should  be  drunk  and  liquor  potassse  given;  if  alkaline,  the 
benzoate  of  sodium  may  be  given.  Laxatives  may  be  required  and 
the  diet  should  be  light  and  nutritious.  The  crude  pyroligneous  acid 
is  applied  to  the  vulva  and  vagina  in  the  acute  stage  of  vulvovaginitis. 
This  may  be  done  by  means  of  a  swab  or  by  injecting  through  a  syringe. 

In  vulvitis  furunctdosis  the  pustules  should  be  opened  with  a  knife, 
the  surface  cleansed  with  an  antiseptic,  and  an  antiseptic  dressing 
applied.  For  this  purpose  the  author  uses  a  pad  of  sterile  gauze  moist- 
ened with  the  following  solution:  formalin,  1  part;  glycerin,  400  parts; 
water,  2000  parts.  When  the  inflammatory  reaction  is  great,  the  surface 
may  be  bathed  with  lead  water  and  laudanum.  The  mixed  vaccines 
(staphylococcic)  are  worthy  of  a  trial  in  these  cases. 

Tuberculous  vulvitis  demands  excision  of  the  involved  tissues  and, 
when  possible,  suturing  of  the  wound. 

Syphilitic  vulvitis  demands  specific  treatment,  both  general  and  local. 
Diphtheritic  vulvitis  will  respond  to  the  antitoxin. 

Chronic  Stage. — In  chronic  vulvitis  the  underlying  cause  in  the 
majority  of  cases  is  gonorrhea,  the  treatment  of  which  does  not  differ 
essentially  from  that  of  the  acute  stage.  It  is  not  necessary  to  confine 
the  patient  to  bed,  though  only  moderate  exercise  is  permitted.  ,  Clean- 
liness must  be  maintained  by  douches  of  bichloride  of  mercury,  1  to 
4000,  or  formalin,  1  to  4000;  the  irritated  surface  is  to  be  kept  dry  and 
the  irritation  relieved  by  dusting  powders.  On  alternate  days  the 
surface  is  painted  with  nitrate  of  silver,  grains  10  to  fluidounce  1.  To 
excoriated  surfaces  more  concentrated  solution  of  silver  nitrate  may  be 
applied.    In  stubborn  cases  the  vulva  and  vagina  may  be  packed  with 


INFLAMMATIONS  OF  THE  VULVA 


401 


sterile  gauze  saturated  with  a  25  per  cent,  solution  of  argyrol.  Care 
should  be  given  the  bowels  and  urine,  as  suggested  above. 

Bartholinitis. — Bartholinitis  is  a  frequent  accompaniment  of  a 
gonorrheal  infection.  In  the  majority  of  cases  only  the  mouth  of  the 
gland  is  infected.  It  not  infrequently  happens  that  there  is  an  occlusion 
of  the  outlet  of  the  gland,  leading  to  a  distention  of  the  gland  into  a 
cyst  containing  a  clear  sterile  fluid.  As  a  result  of  secondary  infection 
with  pyogenic  microorganisms  an  abscess  may  develop  within  the 
gland. 

Vulvitis  Furunculosa. — Multiple  small  abscesses  are  found  upon 
the  labia  majora,  less  frequently  upon  other  portions  of  the  vulva. 
These  abscesses  are  usually  found  in  the  sebaceous  and  sweat  glands. 
Of   all   the  glands   of  the   vulva,  the    Bartholinean   glands    are  most 


Fig.  279 


Fig.  280 


Enlargement  of  the  vulvovaginal  gland  by 
cyst  or  abscess.     (Schaffer.) 


Right  inguinal  hernia  simulating  vulvo- 
vaginal cyst  or  abscess.  Eversion  of  anterior 
and  posterior  vaginal  walls.     (Schaffer.) 


commonly  infected,  and  gonorrhea  is  the  cause  in  a  great  majority 
of  the  cases.  As  a  rule  the  glands  are  not  extensively  involved.  The 
mouths  alone  of  the  glands  may  be  involved,  giving  rise  to  the  so-called 
maculse  gonorrheica  of  Sanger.  Gebhard  states  that  when  suppuration 
occurs  in  the  gland  there  is  always  a  mixed  infection  of  the  gonococcus 
and  staphylococcus.  It  is  unusual  to  observe  Bartholinitis  in  infants. 
The  size  which  these  infected  glands  may  attain  is  from  that  of  a  split 
pea  to  a  man's  fist. 

The  infected  Bartholinean  gland  is  located  in  the  labia  majora; 
is  round  or  oval,  firm  or  fluctuating,  and  may  or  may  not  be  tender. 

It  is  to  be  differentiated  from  hernia  into  the  labium  (Figs.  279  and 
280).  The  latter  is  not  tender,  is  elongated,  tympanitic  on  percussion, 
26 


402     CIRCULATORY  DISTURBANCES  OF  VULVA  AND  VAGINA 

and  may  be  made  to  disappear  by  taxis.    When  reduction  of  the  hernia 
is  impossible,  and  when  strangulation  and  gangrene  of  the  gut  have 

Fig.  281 


f/  .mh  \ 


VAGINA       Wy  'RIh    flUiwi   '^^x,     V    \     \^\^\       VULVO-VAGINAl. 


f/l 


3^- 


mSM  //W/,. 


The  vulvovaginal  gland  or  gland  of  Bartholin.      (The  dotted  line  indicates  the  limits  of  the  bulb  of 

the  vagina.      (Testu^.) 


Fig.  282 


Fig    283 


Cyst  of  the  gland  of  Bartholin, 


Line  of  suture  after  removal  of  the  cyst  of 
the  gland  of  Bartholin. 


INFLAMMATIONS  OF  THE  VULVA  403 

occurred,  the  usual  symptoms  of  intestinal  obstruction  will  suggest 
the  probable  nature  of  the  swelling.  Evidence  of  gonorrheal  infection 
elsewhere  in  the  genito-urinary  tract  will  be  suggestive. 

Treatment. — In  the  absence  of  the  development  of  a  cyst  or  abscess, 
the  treatment  does  not  differ  from  that  recorded  above  in  the  discussion 
of  vulvitis.  When  a  cyst  or  abscess  has  formed,  excision  is  the  only 
treatment  to  be  considered.  This  can  be  done,  as  a  rule,  under  local 
anesthesia  by  the  hypodermic  injection  of  Schleich's  solution,  made 
as  follows:  morphine  sulphate,  gr.  -yq]  cocaine  hydrochlorate,  gr.  \; 
aqua  pura,  oz.  1. 

When  no  pus  is  present  the  wound  is  closed  with  sutures  of  plain 
catgut,  and  when  pus  is  present  the  cavity  is  packed  with  strips  of 
iodoform  gauze  and  allowed  to  heal  by  granulation.  In  making  the 
incision  the  skin  surface  should  be  chosen  unless  an  abscess  is  point- 
ing on  the  mucous  surface;  this  obviates  the  presence  of  a  tender 
cicatrix. 

Pruritus  Vulvae. — Pruritus  vulvae  is  a  term  applied  to  an  itching  of 
the  vulva,  accompanied  by  swelling  of  the  parts  and  nervous  irritability. 
The  most  frequent  area  involved  is  the  clitoris;  next  in  order  of 
frequency  are  the  labia,  vestibule,  mons  veneris,  perineum,  and 
anus. 

Symptoms. — The  lesion  is  usually  symptomatic,  but  there  is  a  small 
proportion  of  cases  in  which  it  appears  to  be  idiopathic.  iVs  a  symp- 
tomatic lesion  the  underlying  causes  are  largely  attributable  to  mechan- 
ical and  infectious  irritations  of  the  vulva.  As  mechanical  irritations, 
masturbation  and  excessive  sexual  intercourse  are  excitants,  which 
ma}'  be  the  result  as  well  as  the  cause  of  pruritus;  also,  the  wearing  of 
filthy  pessaries,  uncleanliness  of  the  vulva,  irritating  urine  in  vesico- 
vaginal fistulae  and  diabetes,  and  the  irritating  discharge  from  malignant 
growths.  Of  the  infectious  agencies  may  be  mentioned  parasites, 
including  the  oidium  albicans,  pediculi,  and  intestinal  worms.  Any 
condition  bringing  about  passive  congestion  of  the  pelvis  may  cause 
pruritus  vulvae  in  the  same  manner  as  hemorrhoids  cause  pruritus 
ani. 

Many  of  the  pelvic  lesions  may  reflexly  cause  itching  of  the  vulva. 
Pruritus  vulvae,  associated  with  dryness  and  sensitiveness  of  the  skin, 
suggests  the  presence  of  kraurosis  of  the  vulva.  Disorders  of  the 
blood  may  account  for  some  cases.  Finally,  a  small  number  are  to 
be  attributed  to  neuroses,  though  a  mechanical  cause  is  always  to  be 
sought.  The  condition  is  frequently  associated  with  pregnancy  and 
without  assignable  cause. 

Diagnosis. — The  diagnosis  of  pruritus  vulvae  may  be  made  from  the 
patient's  complaint  of  itching,  but  it  is  most  essential  that  the  cause 
of  the  pruritus  be  determined  by  a  general  as  well  as  local  physical 
examination. 

Pruritus  vulvae  may  generally  be  considered  as  a  symptom  of  some 
general  or  local  lesion.  Every  case  of  pruritus  should  suggest  the 
possibility  of  diabetes,  and  should  call  for  a  urinalysis.    The  presence 


404      CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

of  irritating  vaginal  discharges,  of  worms,  and  of  parasites  are  to  be 
sought.    The  sexual  habit  of  the  patient  should  be  a  subject  of  inquiry. 

The  one  dominating  symptom  is  itching  over  part  or  all  of  the  vulva. 
So  distressing  is  this  itching  that  the  patient  becomes  irritable  and 
nervous;  she  shuns  society,  and  may  even  develop  into  a  maniac  or 
suicide.  The  itching  is  always  worse  at  the  menstrual  period,  during 
sexual  intercourse,  in  warm  weather,  and  after  physical  exertion. 

Local  changes  in  the  skin  surface  of  the  vulva  are  commonly  present 
and  are  largely  due  to  scratching. 

Webster  and  Sanger  studied  independently  the  histological  changes 
of  the  skin  removed  from  the  affected  area.  Webster  found  the  genital 
corpuscles  of  Krause  in  the  clitoris,  and  called  them  tactile  corpuscles. 
Nerve  endings  in  the  form  of  end-bulbs  were  found  in  large  numbers 
A  fibrosis  of  the  corpuscles  of  Krause  and  of  the  end-bulbs  and  nerves 
were  found  by  Webster  and  confirmed  by  Sanger.  There  was  a  marked 
small  round-cell  infiltration  in  the  subepithelial  tissues,  and  the  super- 
ficial epithelium  was  largely  removed. 

Treatment. — The  treatment  is  general  and  local. 
General  Treatment. — The  urine  is  rendered  bland  and  non-irritating 
by  drinking  freely  of  milk  and  water.  Diuretics  are  given  to  control 
an  overacidity  or  alkalinity  of  the  urine.  x\ll  alcoholic  drinks  are 
forbidden.  The  bowels  are  carefully  regulated  by  laxatives.  Exercise 
is  to  be  taken  with  caution,  inasmuch  as  too  much  walking  excites 
the  itching.  When  the  patient  is  neurotic  the  rest  cure  may  prove 
of  great  benefit.  Change  of  environment  is  frequently  beneficial.  Sleep 
is  often  disturbed,  demanding  hypnotics.  For  this  purpose  the  opiates 
are  to  be  avoided,  and  in  their  stead  bromides,  sulphonal,  trional, 
and  veronal,  in  large  doses,  are  given  at  bedtime. 

Local  Treatment. — Vaginal  douches  are  essential  to  the  keeping  of 
the  vulvar  surface  free  from  the  vaginal  discharges.  For  this  purpose 
creolin  (1  to  200),  lysol  (1  to  200),  boric  acid  in  a  saturated  solution, 
and  carbolic  acid  (1  to  1000)  are  used.  When  the  douches  do  not  pre- 
vent the  leucorrheal  discharges  from  soiling  the  vulva,  a  sterile  lambs' 
wool  tampon  should  be  placed  in  the  vagina.  These  tampons  should 
be  saturated  with  1  part  of  boroglycerin  and  3  parts  of  glycerin,  or 
may  be  dusted  with  boric  acid  powder  or  equal  parts  of  boric  acid  and 
bismuth. 

To  relieve  the  itching,  countless  remedies  have  been  applied  to  the 
affected  surface.    The  following  are  some  of  the  most  reliable  remedies: 

1.  Ten  per  cent,  cocaine. 

2.  Five  per  cent,  carbolic  acid. 

3.  Carbolo-salve,  5  per  cent. 

4.  Pure  ichthyol,  applied  once  or  twice  daily. 

5.  Lead  water  and  laudanum. 

6.  Corrosive  sublimate,  1  grain  to  the  ounce  of  the  emulsion  of 
almonds. 

7.  Menthol  applied  by  a  pencil. 

8.  Oxide  of  zinc  ointment. 


INFLAMMATIONS  OF  THE  VULVA 


405 


9. 


10. 


I^ — ^Acidi  carbolici oij 

Mentholi gr.  v 

Unguenti  petrolati       .... §ij 

Unguenti  creosoti §j 

I^ — -Mentholi gr.  viij 

Acidi  carbolici 3j 

Ung.  camphors, 

Ung.  petrolati aa  5iij 

Fig.  2S4  Fig.  285 


Excision  of  the  vulva  for  tuberculosis  of  the 
vestibule.  Step  1.  Outlines  present  area  of 
denudation.     (After  Kelly.) 


Excision  of  the  vulva.     Step  2, 


The  a:-rays  are  worthy  of  trial  in  obstinate  cases  of  pruritus  which 
have  not  yielded  to  the  application  of  local  remedies  and  before  resorting 
to  surgical  measures. 

An  analysis  of  the  urine  should  never  be  neglected,  and  if  nephritis 
or  diabetes  be  discovered,  the  proper  line  of  treatment  will  be  suggested. 
Pediculi  may  be  found  in  the  pudendal  hair.  They  are  quickly  disposed 
of  by  shaving  the  parts,  washing  with  green  soap,  and  applying 
carbolo-salve  (10  per  cent.).  Ascarides  may  be  detected  by  watching 
the  stools. 

Irritating  vaginal  discharges  are  to  be  removed  by  treatment  directed 
to  their  underlying  cause  and  by  frequent  vaginal  douches. 


406     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

Surgical  Treatment. — When  all  else  ha^  failed,  excision  of  the  affected 
parts  must  be  resorted  to.  This  may  involve  the  sacrifice  of  part  or 
all  of  the  vulva.     (See  Figs.  284,  285,  286,  and  287.) 


Fig.  286 


Fig.  287 


/         / 


j\y/p^^''^ 


Excision  of  the  vulva.     Step  3. 


Excision  of  the  vulva.     Step  4. 


INFLAMMATIONS  OF  THE  VAGINA 


Vaginitis  (Colpitis). — ^Vaginitis  rarely  exists  alone.  As  a  rule,  it  is 
associated  with  vulvitis  and  endometritis,  and  not  infrequently  with  a 
similar  involvement  of  the  entire  genital  tract. 

Etiology. — With  few  exceptions  vaginitis  is  due  to  bacterial  invasion. 
Mechanical  and  thermic  irritants  are  accountable  for  a  small  number 
of  cases. 

Of  the  microorganisms  causing  vaginitis,  the  gonococcus  is  by  far 
the  most  frequent.  A  purulent  discharge  from  the  cervix  containing 
the  gonococcus  may  fail  to  infect  the  vagina  because  of  the  protecting 
epithelium,  which,  when  intact,  resists  all  bacterial  invasion. 

If,  however,  the  epithelium  of  the  vagina  is  lost  or  its  vitality  is 
lowered  infection  will  follow.  We,  therefore,  find  primar}^  gonorrheal 
vaginitis  less  frequently  in  the  young  than  in  those  of  advanced  years, 
where  the  epithelium  has  lost  its  full  power  of  resistance  and  is  more 


INFLAMMATIONS  OF  THE  VAGINA  407 

or  less  desquamated.  Repeated  attacks  of  vaginitis  may  result  from 
contamination  by  the  secretions  of  the  uterus,  tubes,  and  urethra. 
Some  assert  that  chronic  gonorrheal  vaginitis  does  not  exist. 

Injudicious  exercise  and  sexual  excesses  may  be  the  explanation  of 
exacerbations. 

Puerperal  vaginitis  is  nearly  always  caused  by  the  staphylococcus 
or  streptococcus.  The  Klebs-Loeffler  bacillus  is  rarely  the  cause 
of  vaginitis.  The  streptococcus  of  erysipelas  is  occasionally  found, 
particularly  in  infants.  The  presence  of  the  oidium  albicans  and 
leptothrix  has  been  demonstrated.  Entozoa  can  invade  the  vagina 
from  the  rectum.  Ascarides  and  similar  parasites  of  the  intestines 
may  invade  the  vagina  and  set  up  a  vaginitis. 

Infections  from  the  bowel,  as  from  dysentery  and  typhoid  fever, 
may  invade  the  vagina.  Infection  may  also  travel  from  the  bladder 
to  the  bowel.  An  irritating  and  infectious  discharge  from  the  uterus 
or  from  a  pelvic  abscess  opening  into  the  vagina  ma^^  infect  the  vagina. 
It  is  probable  that  maceration  of  the  epithelium  by  fluids  used  in 
douching,  favors  infection  from  such  discharges. 

The  secretions  from  malignant  growths  of  the  uterus  are  particularly 
irritating  to  the  vaginal  mucosa. 

Trauma  from  ill-fitting  and  foul  pessaries,  from  tampons  saturated 
with  irritating  secretions,  and  from  masturbation  predisposes  to 
infection.  Schultze  claims  that  decomposition  of  stagnated  menstrual 
blood  behind  the  hymen  in  chlorotic  girls  is  not  infrequently  a  cause- 
of  vaginitis. 

Tumors  lying  within  the  vagina  may  act  as  mechanical  irritants  to 
the  vaginal  mucosa. 

Anatomical  Diagnosis. — The  following  morphological  forms  are 
recognized : 

1.  Catarrhal  Vaginitis. — Catarrhal  vaginitis  is  recognized  by  a 
reddening,  swelling,  and  increased  secretion  of  the  vaginal  mucous 
membrane.  These  changes  are  proportionate  to  the  degree  of  acuteness 
and  intensity  of  the  infection.  The  surface  is  rarely  uniformly  red, 
but  rather  mottled  red  and  gray.  In  the  chronic  stage  slight  reddish 
elevations  stud  the  surface.  These  elevations  are  particularly  prominent 
in  old  age  when  contrasted  with  the  smooth,  pale  gray  background. 

The  microscope  shows  a  diffuse  round-cell  infiltration  and  capillary 
congestion  of  the  subepithelial  connective  tissue.  There  may  be  more 
or  less  desquamation  of  the  surface  epithelium.  The  deep  layers  of 
connective  tissue  are  rarely  involved.  In  the  senile  variety,  punctate 
hemorrhages  are  particularly  liable  to  occur  in  the  connective  tissue. 
Gebhard  speaks  of  a  variety  called  croupous  vaginitis,  in  which  there  is 
formed  on  the  surface  a  false  membrane  composed  of  fibrin  and  leuco- 
cytes, together  with  desquamated  and  degenerated  epithelium.  He 
observes  that  a  similar  lesion  is  often  found  in  the  bowel,  and  reasons 
that  there  is  a  specific  cause  underlying  both  conditions. 

2.  Ulcerative  Vaginitis. — It  is  possible  for  ulcers  to  develop  in 
the  advanced  stage  of  catarrhal  vaginitis;  this,  however,  is  exceptional. 


408     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

The  loss  of  epithelium  is  usually  superficial,  and  in  healing  does  not 
lead  to  cicatrization. 

(a)  Puerperal  ulcers  of  the  vagina  arise  from  infection  of  abrasions 
and  lacerations  acquired  in  labor.  A  diphtheritic  membrane  of  a  gray 
or  yellowish-gray  color  forms  over  the  ulcerated  surface.  The  lesion 
may  extend  deeply  into  the  vaginal  wall  and  into  the  paravaginal 
connective  tissue.  Pelvic  abscesses  and  suppurative  peritonitis  may 
follow  from  extension  of  the  infection.  A  diffuse  tumefaction  and 
reddening  of  the  vaginal  mucous  membrane  may  extend  from  the 
ulcers,  giving  the  appearance  of  erysipelas.  Stenosis  and  atresia  of 
the  vagina  may  follow  healing  by  cicatrization,  particularly  when  the 
paravaginal  tissues  are  involved. 

(6)  True  diphtheritic  ulcers  of  the  vagina,  in  which  the  Klebs- 
Loeffler  bacillus  appears,  is  a  rare  finding,  and  almost  always  develops 
during  the  puerperium. 

(c)  Tuberculous  ulcers  of  the  vagina  are  of  rare  occurrence.  Such 
ulcers  are  shallow,  with  irregular  undermined  margins.  The  base 
and  margins  are  studded  with  miliary  tubercles,  in  which  the  tubercle 
bacillus  may  be  demonstrated. 

(d)  Syphilitic  ulcers  in  the  primary  stage,  with  elevated  indurated 
margins,  are  more  common  than  those  of  the  secondary  or  tertiary 
stage.  Ulcers  of  the  vagina  complicating  the  infectious  diseases,  as, 
for  instance,  typhoid  fever  and  smallpox,  are  occasionally  seen. 

(e)  Decubitus  ulcers  arising  frona  pressure  by  foreign  bodies  in  the 
vagina  show  great  variation  in  extent  and  form.  The  common  cause 
of  decubitus  ulcers  is  the  wearing  of  ill-fitting  pessaries,  which,  through 
pressure,  cause  a  superficial  slough  of  the  mucosa.  The  necrosis  may 
extend  deep  into  the  tissues  and  result  in  the  development  of  a  vesico- 
vaginal fistula.    Such  ulcers  may  attain  the  size  of  a  saucer. 

3.  Tuberculous  Vaginitis. — But  one  case  of  primary  tuberculosis 
of  the  vagina  has  been  reported  (Friedlander) .  The  usual  tuberculous 
lesions  are  found — that  is  to  say,  local  or  general  dissemination  of 
tubercles,  larger  tuberculous  nodules,  and  caseous  masses  with  ulcers. 
The  microscope  reveals  the  usual  structure  of  tubercles:  giant  cells, 
small  round  cells,  endothelioid  cells,  and  tubercle  bacilli. 

By  far  the  greater  number  are  secondary  to  tuberculosis  of  the 
uterus,  tubes,  vulva,  cervix,  rectum,  and  bladder.  The  infection 
may  rarely  be  conveyed  by  the  blood.  Primary  infection  may  be 
acquired  by  direct  infection  from  the  husband  and  from  the  examining 
finger  and  instruments. 

4.  Emphysema  Vagina  (Colpitis  Emphysematosis). — As  the  result 
of  some  sort  of  an  infection,  numerous  small  cysts  filled  witb  gas  are 
found  in  the  subepithelial  connective  tissue.  The  lesion  is  most  fre- 
quently seen  in  pregnancy  and  the  puerperium.  As  a  rule,  the  cysts 
disappear  within  three  months  after  labor. 

Wenkel  first  described  them  as  retention  cysts  formed  from  vaginal 
glands.  Zweifel  first  demonstrated  them  to  be  the  result  of  fermentation. 
Eisenlohr  proved  the  presence  of  gasogenic  bacteria  in  the  connective- 


INFLAMMATIONS  OF  THE  VAGINA  409 

tissue  spaces  of  the  submucosa  and  of  the  lymph  spaces.  There  can 
be  no  doubt  as  to  the  microbic  origin  of  the  lesion.  Through  a  speculum 
the  vesicles  appear  dark  bluish  red  in  color.  Pressure  causes  them  to 
temporarily  disappear.  If  the  vagina  is  partly  filled  with  clear  fluid 
and  the  vesicles  punctured  with  a  needle,  gas  will  escape  in  bubbles. 

5.  CoNDYLOMATOUS  Yagixitis. — Groups  of  warty  excrescences  are 
found  in  the  vagina  as  a  further  extension  of  a  similar  growth  of  the 
vulva.  The  whole  vaginal  surface  may  be  covered  with  the  warty 
growths. 

6.  Senile  Vaginitis. — A  form  of  vaginitis  that  is  characterized 
by  the  formation  of  adhesions  between  the  vaginal  walls  and  between 
the  vaginal  walls  and  cervix  is  often  seen  in  old  age.  The  vaginal 
epithelium  becomes  devitalized  and  desquamated,  thus  rendering  the 
tissues  susceptible  to  infection.  The  symptoms  complained  of  are 
leucorrhea,  painful  intercourse,  a  feeling  of  weight  in  the  pelvis,  and 
the  occasional  loss  of  a  moderate  amount  of  blood. 

On  examination  through  a  vaginal  speculum,  the  mucous  membrane 
of  the  vagina  is  found  to  be  pale  and  glistening,  the  rugosities  are  lost, 
and  here  and  there  are  seen  excoriated  areas.  The  vaidt  of  the  vagina 
is  irregularly  obliterated  by  adhesions  which  usually  separate  readily, 
leaving  a  raw,  bleeding  surface.  In  well-advanced  cases  the  entire 
vaginal  cavity  may  be  obliterated  by  firm  adhesions. 

Clinical  Diagnosis. — In  all  forms  of  vaginitis  there  is  an  excessive 
secretion,  varying  in  quantity  and  character.  The  secretion  is  derived 
in  part  from  the  uterus  and  cervix.  It  is  serous,  mucous,  or  purulent. 
This  so-called  leucorrhea  ("whites")  is  usually  the  first  symptom. 
Following  this  is  itching  and  bm"ning,  which  is  aggravated  by  exercise. 
When  caused  by  gonorrhea  these  symptoms  may  appear  within  twenty- 
four  hours  from  the  time  of  the  infection.  In  addition  to  the  above 
symptoms  there  is  usually  burning  and  smarting  on  urinating,  caused 
by  a  urethritis. 

When  pus  can  be  expressed  from  the  urethra,  the  diagnosis  of  gonor- 
rhea is  made  with  reasonable  certainty.  If  in  addition  the  Bartholinean 
glands  are  infected  there  can  be  little  doubt  as  to  the  gonorrheal  origin 
of  the  lesion. 

Vesical  and  rectal  tenesmus  are  present  in  the  acute  stage.  In  the 
mild  forms  and  in  the  chronic  stage  the  patient  may  not  complain. 

The  diagnosis  has  to  do,  first,  with  the  recognition  of  the  vaginitis; 
next,  with  the  possible  extension  of  the  lesion  to  neighboring  structures; 
and,  finally,  with  the  underlying  cause  of  the  infection. 

Direct  inspection  should  determine  the  presence  of  vaginitis.  The 
Sims  speculum  should  be  used  with  the  patient  in  the  Sims  position. 
There  is  more  or  less  sensitiveness  to  the  touch  of  the  examining  finger, 
and  a  roughness  of  the  surface  may  be  detected. 

The  recognition  of  extension  to  the  upper  genital  tract  involves 
the  diagnosis  of  endometritis  and  salpingitis.  To  determine  whether 
the  secretion  is  from  the  vagina  or  from  the  uterus  the  Schultze  method 
is  employed.     The  vagina  is  cleansed  with  a  douche  of  sterile  water, 


410     CIRCULATORY  DISTURBANCES  OF  VULVA  AND  VAGINA 

a  plug  of  sterile  cotton  is  placed  against  the  cervix,  and  after  remaining 
there  several  hours  it  is  removed.  If  the  secretion  is  collected  on  the 
top  of  the  plug,  the  discharge  comes  from  the  uterus;  if  it  collects 
around  the  plug,  the  discharge  is  from  the  vagina. 

Recognition  of  the  cause  of  the  infection  is  not  always  possible. 
Gonorrhea  is  so  frequently  the  cause  that  it  must  first  be  excluded 
before  considering  other  possible  causes.  In  the  acute  stage  the  gono- 
coccus  can  usually  be  found  in  the  secretion,  but  not  often  in  the 
chronic  stage.  When  beginning  a  few  days  after  marriage  and  when 
associated  with  burning  on  urinating,  it  is  highly  probable  that  gonor- 
rhea is  the  underlying  cause. 

Treatment. — The  treatment  of  vaginitis  is  best  discussed  under  the 
headings  of  acute  and  chronic  forms. 

Acute  Vaginitis. — Rest  in  bed  is  the  most  important  desideratum 
in  the  management  of  acute  cases.  It  should  be  enjoined  throughout 
the  entire  acute  stage. 

Cleanliness  must  be  maintained  if  the  disease  is  to  be  prevented 
from  passing  into  a  chronic  state.  For  this  purpose  vaginal  douches 
are  given  two  or  more  times  daily.  Aside  from  the  mechanical  cleansing 
effect  of  the  douche,  an  antiseptic  added  to  the  sterile  douche  water 
will  materially  lessen  the  inflammatory  reaction  by  destroying  the 
pathogenic  microorganisms  lying  within  the  vagina.  For  this  purpose 
the  author  prefers  formalin  in  the  proportion  of  1  to  2000.  The  douche 
should  be  given  in  the  recumbent  position  and  at  a  temperature  of 
110°.    About  four  quarts  of  solution  should  be  used. 

Local  applications  are  effectively  applied  to  the  vaginal  mucosa. 
For  gonorrheal  vaginitis  the  silver  salts  are  preferred.  In  the  early 
part  of  the  acute  stage,  antiseptic  vaginal  douches  alone  should  be 
given.  As  the  acute  stage  subsides,  2  ounces  of  a  4  per  cent,  solution 
of  silver  nitrate  may  be  poured  through  a  cylindrical  speculum  into 
the  vagina  and  repeated  every  three  to  seven  days.  Each  night  a 
tampon  of  absorbent  cotton,  saturated  with  a  25  per  cent,  solution  of 
argyrol  or  protargol,  should  be  inserted  and  left  overnight. 

Astringent  powders  have  been  used  with  good  effect  as  a  dusting 
powder  to  the  vaginal  mucous  membrane.  These  powders  are  calomel, 
boric  acid,  and  bismuth,  used  smgly  or  in  combination.  They  are 
applied  after  cleansing  the  vagina  with  a  douche  and  drying  the  surface 
with  sterile  swabs  of  cotton.  A  half-ounce  of  the  powder  is  introduced 
on  the  top  of  a  dry  tampon  of  sterile  absorbent  cotton.  The  treatment 
should  be  repeated  three  or  four  times  a  week  for  an  indefinite  period. 
When  there  is  a  tendency  to  the  formation  of  adhesions,  the  surfaces 
should  be  kept  apart  by  vaginal  packs  of  antiseptic  gauze. 

In  ulcerative  vaginitis,  aside  from  antiseptic  vaginal  douches,  the 
ulcers  should  be  cauterized  with  a  20  per  cent,  solution  of  silver  nitrate 
or  with  the  Paquelin  cautery. 

In  emphysematous  vaginitis,  antiseptic  douches  should  be  given 
cautiously  during  pregnancy.  The  temperature  should  not  exceed 
100°,   low  pressure  should  be  maintained,  and  the   duration  of    the 


INFLAMMATIONS  OF  THE  VAGINA  ■      411 

douche  should  not  exceed  five  minutes.  These  precautions  should  be 
taken  in  view  of  the  danger  of  interrupting  pregnancy. 

In  the  absence  of  pregnancy,  emphysematous  vaginitis  may  be 
treated  with  prolonged  hot  antiseptic  douches  and  the  nightly  applica- 
tion of  glycerin  and  ichthyol  tampons. 

Condylomata  Acuminata. — Excision  followed  by  cauterization  is 
the  most  effective  means  of  treatment.  This  usually  requires  a  general 
anesthetic. 

When  operation  is  contra-indicated  for  any  reason,  local  application 
of  equal  parts  of  calomel  and  salicylic  acid  may  be  tried  as  a  dusting 
powder,  though  the  results  are  not,  as  a  rule,  satisfactory. 

When  complicating  pregnancy  the  condylomata  should  not  be 
removed  before  labor  for  fear  of  interrupting  pregnancy.  Sitz  baths 
are  of  value  in  relieving  pain;  they  may  be  given  one  or  more  times 
daily.     Dilute  lactic  acid  has  been  applied  with  good  results. 

Chronic  Vaginitis. — Little  progress  may  be  made  in  the  treatment 
of  chronic  vaginitis  so  long  as  the  exciting  cause  exists.  It  is  therefore 
essential  that  the  irritating,  infectious  discharges  from  the  uterus  be 
removed;  that  foreign  bodies  within  the  vagina,  such  as  tumors  and 
pessaries,  be  removed,  and  above  all  that  cleanliness  be  maintained. 

Rest. — It  is  not  required,  nor  is  it  advisable,  that  rest  in  bed  be 
enjoined.  Well-regulated  exercise  and  fresh  air  are  of  value.  Sexual 
rest,  however,  is  essential  to  a  good  result. 

Diet. — The  food  should  be  nutritious  and  easily  digested. 

Bowels. — Constipation  must  be  prevented  by  the  use  of  mild  cath- 
artics and  the  regulation  of  the  diet. 

Local  Apijlications. — When  the  vaginitis  is  of  gonorrheal  origin, 
douches  of  formalin,  1  to  4000,  should  be  given  twice  daily.  The 
vagina  should  be  packed  with  sterile  gauze  or  cotton  tampons  saturated 
with  a  25  per  cent,  solution  of  argyrol  or  protargol.  These  packs  are 
best  introduced  at  bedtime  and  removed  in  the  morning.  They  may 
be  repeated  nightly  for  an  indefinite  period.  If  the  inflammatory 
reaction  does  not  subside  readily,  the  vaginal  walls  should  be  swabbed 
freely  once  a  week  with  a  10  per  cent,  solution  of  silver  nitrate.  Before 
swabbing  with  silver  nitrate,  the  vaginal  cavity  should  be  loosely  packed 
with  an  antiseptic  gauze;  this  should  be  allowed  to  remain  for  twenty- 
four  hours.  It  is  seldom  necessary  to  continue  the  applications  of 
silver  nitrate  more  than  six  weeks,  but  the  vaginal  douching  of  formalin 
should  be  continued  for  a  much  longer  period. 

Active  treatment  should  not  be  discontinued  until  all  evidence  of 
inflammation  has  disappeared.  In  gonorrheal  infections  the  one  reliable 
test  of  cure  is  the  repeated  bacteriological  examination  of  the  vaginal 
secretions,  with  negative  findings. 

Paravaginitis. — By  paravaginitis  is  understood  an  inflammation 
involving  the  connective  tissue  immediately  surrounding  the  vagina. 
As  a  rule,  it  is  a  staphylococcus  infection  leading  to  the  formation  of 
localized  abscesses.  Other  possible  causes  are  wound  infections  following 
operations  and  attempts  to  induce  abortion;  ill-fitting  pessaries,  which 


412     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 

have  ulcerated  through  the  vaginal  wall;  infectious  diseases,  such  as 
dysentery  and  typhoid  fever,  where  the  infection  is  conveyed  through 
the  bowel  or  bladder  into  the  paravaginal  connective  tissue,  and  in 
inflammatory  diseases  of  the  rectum  and  bladder  extending  to  the 
vagina. 

Veit  describes  a  peculiar  form  which  he  designates  as  paravaginitis 
phlegmonosa  dessicans.  But  few  cases  have  been  recorded.  One 
was  ascribed  to  gonorrhea;  others  may  have  been  due  to  criminal 
abortion,  and  in  two  instances  no  cause  was  assigned.  Undoubtedly 
the  lesion  may  arise  as  a  complication  of  contagious  and  infectious 
diseases.     Cicatricial   contraction   of  the  vagina  is  the  final   result. 

Vaginismus. — ^Vaginismus  is  a  term  applied  to  a  condition  in  which 
there  are  spasmodic  contractions  of  the  vulvovaginal  orifice.  These 
spasms  may  involve  the  levator  ani  muscles,  the  thighs,  and  occasion- 
ally the  muscles  of  the  body  in  general. 

Causes. — Vaginismus  is  a  symptom,  not  a  disease.  It  is  due  to  local 
causes,  though  neurotic  individuals  are  more  often  affected,  and  it  is 
assumed  that  their  general  nervous  state  has  much  to  do  with  the 
condition. 

1.  Traumatisms. — Injuries  sustained  in  coitus,  with  subsequent  irri- 
tation, are  common  causes.  In  this  manner  the  hymeneal  tags  become 
irritated,  and  excoriated  areas  and  fissures  appear  at  the  vulvovaginal 
orifice,  and,  as  a  result,  vaginismus  develops. 

2.  Urethral  caruncle. 

3.  Fissures  in  the  fourchette,  urethra,  and  rectum. 

4.  Inflammations  of  the  vulva,  vagina,  cervix,  bladder,  urethra,  and 
rectum. 

5.  Coccygodynia. 

6.  Masturbation. 

7.  Excessive  venery. 

Symptoms. — The  spasm  may  develop  gradually  or  suddenly,  and 
may  be  confined  to  the  vulvovaginal  outlet  or  may  assume  general 
convulsive  movements.  Cases  may  be  so  exaggerated  as  to  preclude 
intercourse  and  digital  examinations.  As  a  rule,  women  suffering  from 
vaginismus  become  hysterical  and  are  poorly  nourished.  Most  of  them 
are  sterile. 

Diagnosis. — No  difficulty  will  be  experienced  in  making  a  diagnosis. 
The  patient  describes  the  spasm,  and  upon  attempting  to  make  a 
digital  examination,  the  spasms  will  be  produced.  Unless  treated 
these  cases  tend  to  become  worse,  but  with  proper  treatment  the 
prospect  for  cure  is  good. 

Treatment. — ^When  a  cause  can  be  found  it  must  be  removed.  It  is 
not  always  possible  to  demonstrate  a  cause  and  then  the  treatment  is 
directed  to  the  existing  symptoms.  Furthermore,  with  the  removal 
of  the  cause,  the  spasms  will  often  continue  unless  the  vulvovaginal 
outlet  is  thoroughly  stretched. 

Tentative  Treatment. — In  mild  cases  a  2  to  5  per  cent,  solution 
of  cocaine  may  be  applied  by  means  of  a  pledget  of  absorbent  cotton 


INFLAMMATIONS  OF  THE  VAGINA 


413 


to  the  affected  surface.  By  this  means  the  irritabiUty  may  subside 
and  the  conditions  made  favorable  for  intercourse.  Hot  sitz  baths  are 
useful  in  reheving  the  spasms.  A  4  per  cent,  sohition  of  silver  nitrate, 
applied  to  the  affected  surface  twice  a  week,  will  sometimes  give  perma- 
nent relief.  The  general  condition  of  the  patient  must  receive  due 
consideration.  To  this  end  a  psycho-analysis  should  be  made  and 
psychic  treatment  administered.  The  habits  of  life  should  be  carefully 
regulated,  in  view  of  improving  her  general  health.  While  under 
treatment  all  sexual  excitement  must  be  avoided. 

Radical  Treatment. —  Dilatation. — In  severe  and  intractable  cases 
there  must  be  overstretching  of  the  vagina  and  vulvar  outlet.  This 
may  be  accomplished  slowly  and  without  an  anesthetic  by  cocainizing 
the  vulvovaginal  outlet  and  passing  lubricated  graduated  bougies. 
By  patiently  persisting  over  a  period  of  several  weeks  a  cure  may  be 
effected. 


Fig.  288 


Glass  plug  in  the  vagina,  inserted  to  retain  the  patency  of  the  vagina  following  operation 
for  atresia  and  vaginismus. 

Forcible  Dilatation  under  General  Anesthesia. — A  general  anesthetic 
is  given  and  the  vulvar  outlet  is  stretched  with  the  thumbs  to  the 
point  of  yielding.  A  Sims  glass  vaginal  plug  is  then  introduced  that  is 
sufficiently  large  to  keep  the  structures  on  the  stretch.  This  plug 
should  be  worn  continuously  for  one  week,  then  removed,  and  inserted 
for  an  hour  night  and  morning  for  about  one  month.  If  the  patient 
experiences  difficulty  in  inserting  the  plug,  the  parts  may  be  rendered 
insensitive  by  the  application  of  cocaine  (5  per  cent.). 

Incisions. — When  forcible  stretching  fails,  an  incision  is  made  in 
the  median  line  from  the  vaginal  entrance  to  a  point  in  the  perineum 
midway  to  the  anus.  An  incision  one  and  a  half  inches  long  is  next 
made  into  either  vaginal  sulcus  and  converging  at  the  median  incision 
in  the  perineum.    These  incisions  should  extend  through  the  superficial 


414     CIRCULATORY  DISTURBANCES  OF  VULVA  AND   VAGINA 


fascia  and  underlying  muscle  fibers.  Interrupted  catgut  sutures 
(No.  2  chromic)  are  passed  from  above  downward,  uniting  these 
structures. 

Treatment  ivith  a  Hydrostatic  Bag. — In  place  of  specula  and  dilators 
the  Champetier  de  Ribes  bag,  such  as  is  used  in  obstetrical  practice, 
may  be  employed  with  good  effect. 


Fig.  289 


Fig.  290 


Fig.  291 


Operation  for  vaginismus. 
Step  1. 


Operation  for  vaginismus. 
Step  2. 


Operation  for  vaginismus. 
Step  3. 


A  general  anesthetic  is  given  and  a  bag,  5  to  6  cm.  in  diameter,  is 
introduced  and  gradually  distended  with  water.  Care  should  be  taken 
not  to  stretch  the  vaginal  walls  to  the  point  of  rupture.  When  filled, 
traction  is  made  upon  the  bag  until  the  perineum  stretches.  The 
w^ater  is  then  removed  from  the  bag  and  the  bag  extracted. 

A  second  bag,  6  to  7  cm.  in  diameter,  is  next  inserted  and  the  process 
of  stretching  repeated.  After  removal  of  the  bag  the  vagina  is  snugly 
packed  with  iodoform  gauze  for  twenty-four  hours,  after  which  daily 
vaginal  douches  are  given.  The  advantage  of  this  form  of  treatment 
rests  in  the  thorough  stretching  of  not  only  the  vaginal  walls  but  the 
pelvic  floor  as  well. 


CHAPTER  XIX 


INFLAMMATIONS  OF  THE  UTERUS 


Endocervicitis  (Endometritis  Cer- 

VICALIS) 

Erosions  of  the  Cervix 
Simple 
Papillary 
Follicular 
Ulcers  of  the  Cervix 
Decubitus 
Tuberculous 
Cancerous 
Tuberculosis  of  the  Cervix 
Endometritis 

Clinical  Classification 
Acute 
Chronic 

Hemorrhagic 

Catarrhal 

Dysmenorrheic 

Tuberculous 

Gonorrheal 

Decidual 

Puerperal 


■     Postabortive 
Exfoliative 
Senile 
Anatomical  Classification 
Macroscopic 

Hypertrophic 
Fungous 
Villous 
Polypoid 
Ulcerative 
Pseudodiphtheritic 
Microscopic 
Glandular 
Interstitial 
Chronic  Metritis 
Abscess  of  the  Uterus 
Treatment  of  Inflammation  of  the 
Uterus 
Acute  Metritis 
Chronic  Metritis 
Endocervicitis 
Erosions  of  the  Cervix 


ENDOCERVICITIS   (ENDOMETRITIS  CERVICALIS) 


Endocervicitis  is  an  inflammatory  lesion  confined  to  the  cervical 
canal.  Part  or  all  of  the  cervical  endometrium  may  be  involved,  the 
extent  of  the  lesion  varying  from  a  mere  inflammatory  zone  about  the 
external  os  to  a  diffuse  inflammation  of  the  entire  surface,  extending 
above  to  the  internal  os  and  below  to  the  external  os. 

The  diagnosis  should  not  be  difficult,  because  of  the  accessibility  of 
the  lesion  to  direct  inspection  and  exploration.  The  color  of  the  in- 
flamed mucosa  varies  from  a  bright  red  to  a  dull  cyanotic  hue.  The 
surface  may  be  smooth,  but  is  more  often  granular  or  papillary.  The 
arbor  vitse  are  rounded  and  partially  obliterated.  By  touching  the 
surface  with  the  flnger  or  sound,  slight  bleeding  may  be  excited,  and 
it  is  even  possible  for  spontaneous  bleeding  to  occur.  Tenacious, 
glairy  mucus  covers  the  surface  and  may  efi^ectually  plug  the  cervical 
canal.  The  mucus  accumulating  within  the  cervical  canal  may  cause 
pressure  atrophy  of  the  mucosa,  and  thus  dilate  the  canal.  The  secre- 
tion may  be  clear,  transparent  mucus,  or  it  may  be  milky  from  the 
addition  of  leukocytes  and  epithelium. 


416  INFLAMMATIONS  OF  THE  UTERUS 

Mucous  polyps  of  inflammatory  origin  protrude  from  the  mucosa 
into  the  cervical  canal  and  out  through  the  external  os  into  the  vagina. 

Microscopic  examination  of  scrapings  from  the  cervix  is  unsatis- 
factory, for  the  reason  that  the  surface  epithelium  and  glands  are  firmly 
embedded  in  connective  tissue  and  are  not  readily  scraped  away,  as 
is  the  endometrium  of  the  uterine  body.  As  in  endometritis,  we  find 
in  the  cervLx  two  microscopic  forms — the  glandular  and  interstitial. 

Fig.  292 


Mucous  polj-p  of  the  cervix,  showing  transformation  of  the  columnar  epithelium  into  stratified 
squamous  epitheUum.     The  condition  may  be  mistaken  for  maUgnant  degeneration. 


EROSIONS  OF  THE  CERVIX 

An  erosion  of  the  vaginal  portion  of  the  cervix  is  a  mucous  patch 
consisting  of  a  layer  of  columnar  epithelium  and  newly  formed  glands 
lying  beyond  the  external  os  and  replacing  squamous  stratified  epi- 
thelium. Formerly,  erosions  of  the  cervix  were  believed  tQ  be  true 
ulcers,  and  were  vulgarly  called  ''ulcers  of  the  womb."  We  are  indebted 
to  Ruge  and  Veit  for  the  demonstration  of  their  true  character.  The 
red  or  bluish  color  of  the  mucous  patch  is  in  marked  contrast  to  the 
surrounding  pale  and  smooth  vaginal  epithelium.  The  margins  are 
irregular  but  sharply  circumscribed.  The  extent  of  the  lesion  is  variable. 
In  nulliparae  there  is  usually  a  mere  zone  about  the  external  os,  while  in 


PLATE    XIX 


Healed  Follicular  Erosion  of  Cervix,  ^A/ith  Normal  Mucosa 
in  the  Body  of  the  Uterus. 


EROSIONS  OF  THE  CERVIX  417 

multiparae  the  erosion  may  extend  for  some  distance  upon  the  vaginal 
portion  of  the  cervix  and  even  to  the  vault  of  the  vagina.  Isolated 
patches  may  be  seen  on  the  vaginal  portion  of  the  cervix,  with  normal 
vaginal  epithelium  intervening. 

Classification. — Erosions  may  be  classified  as  simple,  papillary,  and 
follicular. 

Simple  Erosion. — Simple  erosion  has  a  smooth  surface  covered  with 
a  single  layer  of  columnar  epithelium.  Newly  formed  glands  may  dip 
into  the  underlying  connective  tissue. 

Papillary  Erosion. — Papillary  erosion,  as  the  name  implies,  presents 
a  papillary  surface.  In  addition  to  the  surface  layer  of  columnar 
epithelium,  there  are  deep  invaginations  in  the  form  of  glands  alternating 
with  elevations  composed  of  new-formed  connective  tissue  and  round 
cells.  The  new-formed  cells  vary  greatly  in  number  and  size  and 
secrete  abundant  mucus.  The  papillary  elevations  are  in  direct  pro- 
portion to  the  connective-tissue  hyperplasia  and  round-cell  infiltration. 


Transition  of  squamous  epithelium  of  vaginal  portion  to  columnar  epithelium  of  the 
cervical  canal.      (Abel.) 

Follicular  Erosion. — Follicular  erosion  is  characterized  by  the  presence 
of  retention  cysts,  the  so-called  "Nabothian  follicles."  These  retention 
cysts  arise  from  the  occlusion  of  the  mouths  of  the  new-forined  glands 
in  the  erosion.  They  are  filled  with  inspissated  mucus.  To  the  touch 
of  the  examining  finger  they  are  likened  to  the  feeling  of  shot  under 
the  skin;  to  the  eye  they  appear  as  rounded  elevations  of  a  gray,  blue, 
or  yellow  color.  In  number  they  range  from  one  to  a  score  or  more, 
and  may  attain  the  size  of  a  hen's  egg,  though  it  is  unusual  for  them 
to  distend  to  a  size  larger  than  a  hazel-nut.  The  epithelium  lining  the 
cyst  becomes  flattened  and  may  be  entirely  lost. 

The  Healing  of  Erosions. — We  speak  of  incomplete  and  of  complete 
healing  of  erosions.  By  this  is  meant  the  replacing  of  the  mucous 
patch  with  squamous  epithelium.  In  complete  healing  of  an  erosion, 
the  surface  epithelium  and  the  glands  of  the  erosion  are  completely 
replaced  by  squamous  epithelium,  thereby  restoring  the  vaginal  portion 
of  the  epithelium  to  its  normal  integrity.  In  incomplete  healing  of  an 
27 


418 


INFLAMMATIONS  OF  THE  UTERUS 


erosion,  the  columnar  epithelium  on  the  surface  of  the  erosion  is  replaced 
by  many  layers  of  squamous  epithelium,  similar  to  that  of  the  surround- 
ing vaginal  mucosa.    The  glands  beneath  are  not  obliterated,  but  are 


Fig.  294 


ftm 


,.<.<•- 

■i',-,,-^ 


':^^ 


g^.VVj.'. 


Papillarj'  erosion  of  the  cervix.  The  squamous  epithelium  has  been  partially  replaced  by  columnar 
epithelium.  The  surface  is  uneven  and  papillary.  The  tissue  is  deeply  infiltrated  with  small  round 
cells,  and  new  glands  are  formed  bj-  the  invagination  of  the  surface  epithehum. 


Fig.  295 


?^e5v>^~ 


S  %M 


>Oy 


'<'& 


?-■■■.  n 


''*'^Z^^^ 


iKLVMREi—r; 


Incompletely  healed  erosion  of  the  cervix.  Mucous  secreting  glands  are  locked  in  by  manj'  layers 
of  squamous  epithehum.  Formerly  the  surface  was  covered  by  a  layer  of  columnar  epithehum  from 
which  the  glands  dipped  into  the  connective  tissue.  The  surface  epithehum  became  transformed 
into  stratified  squamous  epithehum  and  the  glands  were  buried  beneath. 


PLATE    XX 
1 


Erosions  of  Cervix. 

1.  Hyperemia  of  cervix.  3.  Papillary  erosion. 

2.  Simple  erosion.  4.  Simple  erosion  with  stellate  laceration. 


EROSIONS  OF  THE  CERVIX  419 

either  locked  in  beneath  the  squamous  epithehum  or  open  directly 
upon  the  surface,  now  covered  with  squamous  epithelium.  Healing 
of  an  erosion  is  effected  by  metaplasia  of  the  cylindrical  epithelium  into 
many  layers  of  squamous  epithelium  (Fig.  295). 

Differential  Diagnosis  of  Endocervicitis.— A  clinical  diagnosis  of 
endocervicitis  is  commonly  made  from  the  mucous  or  mucopurulent 
secretion  coming  from  the  cervix.  It  is  well  to  discriminate  between 
a  hypersecretion  of  the  cervix  due  to  passive  congestion  and  a  secretion 
which  is  the  expression  of  an  infection.  This,  however,  is  not  always 
possible.     A  mucous  secretion  seen  to  leave  the  cervical  canal  must 

Fig.  296 


.<1 


"   ^'' 


{       V  -  .    -      •      •  »<^Hv>    f 

Incomplete  healing  of  an  erosion  of  the  cervix.  Between  two  sections  of  stratified  squamous  epi- 
thelium is  a  limited  amount  of  columnar  epithelium  which  is  invaginated  in  the  form  of  irregular 
glands.  Numerous  glands  are  locked  in  beneath  the  squamous  epithelium.  In  this  case  the  surface 
was  originally  smooth  and  covered  with  stratified  squamous  epithehum;  the  squamous  epithelium 
became  destroyed  and  replaced  by  a  single  layer  of  columnar  epithehum,  from  which  glands  were 
formed.  Subsequently,  through  a  heaUng  process,  part  of  the  surface  epithelium  was  transformed 
into  stratified  squamous  epithelium  and  the  glands  were  covered  over,  as  seen  above. 


necessarily  come  from  the  cervix,  there  being  no  mucus  in  the  secretion 
of  the  uterine  body  or  Fallopian  tubes.  When  pus  is  mixed  with  the 
mucus  there  can  be  no  doubt  as  to  the  infectious  origin  of  the  secretion. 

Erosions  of  the  cervix  may  closely  simulate  carcinoma.  The  macro- 
scopic appearance  may  be  identical.  The  differential  diagnosis  is  given 
in  Chapter  XXVII.     (See  Plates  XIX,  XX,  and  XXL) 

Ectropion  of  the  lips  of  the  cervix  may  closely  resemble  erosions. 
If  the  lips  of  the  cervix  are  grasped  by  tenacula  and  approximated,  the 
reddened  surface  will  roll  into  the  cervical  canal  and  disappear.  If  an 
erosion  is  present  there  will  be  no  disappearance  of  the  reddened  zone. 


420  INFLAMMATIONS  OF  THE   UTERUS 


ULCERS  OF  THE  CERVIX 

True  ulcers  of  the  cervix  are  of  rare  occurrence.  Formerly  erosions 
were  regarded  as  such. 

Decubitus  Ulcers. — Decubitus  ulcers  of  the  cervix  are  found  in 
prolapse  of  the  uterus  and  as  the  result  of  ill-fitting  pessaries.  Such 
ulcers  may  attain  the  size  of  a  silver  dollar.  They  are  usually  super- 
ficial, with  irregular  outlines;  the  margins  are  not  elevated;  the  base  is 
granular,  firm,  and  covered  by  a  grayish -yellow  secretion.  The  tendency 
to  bleed  is  not  great,  as  compared  with  malignant  ulcers.  Further- 
more, in  contrast  with  carcinoma,  there  is  a  marked  tendency  to  cicatri- 
zation. Under  the  microscope  the  epithelium  is  seen  to  be  lost.  The 
base  is  thickly  beset  with  distended  capillaries  embedded  in  the  meshes 
of  connective  tissue  and  small  round  cells.  This  round-cell  infiltration 
extends  a  variable  distance  into  the  underlying  connective  tissue.  A 
structureless,  necrotic  material  may  collect  upon  the  base  of  the  ulcer. 

Tuberculous  Ulcers. — Tuberculous  ulcers  will  be  described  below. 

Cancerous  Ulcers. — (See  Chapter  XXVII.) 

TUBERCULOSIS  OF  THE  CERVIX 

Tuberculosis  of  the  cervix  as  a  primary  lesion  is  a  rare  finding. 
Beyea  found  sixty-eight  cases  of  primary  tuberculosis  of  the  cervix 
in  the  literature,  and  adds  a  single  case.  In  nine  of  these  cases  the 
lesion  was  confined  to  the  cervix;  in  the  balance  there  was  an  invasion 
of  adjacent  structures.  The  greatest  number  occurred  between  the 
ages  of  twenty-one  and  forty  years;  the  extreme  ages  were  seventeen 
and  seventy-nine.  Beyea  divides  the  pathological  forms  into  the 
ulcerative,  hyperplastic,  and  miliary. 

Tuberculous  ulcers  of  the  cervix  may  follow  primary  tuberculous 
infection  of  the  endometrium;  or,  as  is  more  often  the  case,  a  primary 
infection  of  the  tubes,  with  subsequent  extension  downward  to  the 
uterus  and  cervix.  The  diagnosis  must  be  based  upon  the  finding 
of  giant  cells,  tubercles,  and  of  tubercle  bacilli  in  and  about  the  ulcers. 
The  margins  of  a  typical  tuberculous  ulcer  are  irregular  and  under- 
mined; the  base  of  the  ulcer  is  uneven  and  tends  to  heal  by  cicatrization. 

Miliary  tuberculosis  of  the  cervix  has  seldom  been  recognized.  In 
general,  it  may  be  said  that  tuberculosis  of  the  cervix  closely  resembles 
erosions  and  cancers.  A  positive  diagnosis  can  only  be  made  by  the 
aid  of  the  microscope.  The  clinical  history  and  the  finding  of  tubercu- 
losis elsewhere  in  the  body,  particularly  in  the  upper  genital  tract,  is  of 
importance  in  the  consideration. 

ENDOMETRITIS 

Hitchman  and  Adler  propose  a  radical  change  in  the  classification 
of  endometritis.    The  author  is  in  accord  with  the  statement  of  Frank, 


ENDOMETRITIS  421 

that  these  authors  have  performed  a  valuable  service  in  claiming  that 
the  majorit}^  of  changes  hitherto  classed  as  chronic  glandular  or  inter- 
stitial endometritis  are  physiological  and  not  inflammatory  in  origin — 
that  they  are  the  changes  normally  found  in  the  menstrual  cycle.  But 
Frank  believes  that  they  have  gone  too  far  in  their  conclusions.  While 
the  presence  of  plasma  cells  does  indicate  an  inflammatory  process,  their 
absence  does  not  necessarily  exclude  the  possibility  of  inflammation. 

Matthews  Duncan  once  said  in  a  lecture:  "Who  can  tell  what 
anyone  means  by  endometritis?  Often  its  use  is  the  parent  or  child 
of  ignorance  and  confusion."  There  is  yet  to  be  proposed  an  exact 
and  practical  classification  of  endometritis.  In  the  light  of  present 
knowledge  we  are  unable  to  harmonize  our  clinical,  macroscopic,  and 
microscopic  forms  of  endometritis.  In  making  a  diagnosis  from  promi- 
nent symptoms  and  evident  etiological- factors,  we  are  unable  to  foretell 
the  naked-eye  and  microscopic  findings.  One  and  all  of  the  pathological 
forms  of  endometritis  may  exist  without  clinical  signs.  On  the  other 
hand,  any  of  the  pathological  lesions  of  the  endometrium  may  give 
the  same  clinical  manifestations  as  endometritis.  Furthermore,  these 
symptoms  may  be  present  in  the  absence  of  an  evident  pathological 
change  in  the  endometrium. 

It  is  evident  that  a  clinical  classification  cannot  be  universally 
applied.  While  appropriate  in  the  majority  of  cases,  there  will  be 
a  minority  which  can  only  be  recognized  by  direct  examination  of 
the  endometrium  with  the  naked  eye  or  with  the  microscope.  Indeed, 
it  not  infrequently  occurs  that  the  absolute  diagnosis  is  reserved  for 
a  microscopic  examination  of  scrapings  removed  by  the  curet.  In 
view  of  what  has  been  said  we  will  give  both  a  clinical  and  an 
anatomical   classification. 

Clinical  Classification  of  Endometritis. — Endometritis  may  be  acute 
or  chronic.  The  distinction  between  these  forms  is  usually  not  difficult 
to  make. 

Acute  Endometritis. — In  acute  infections  of  the  endometrium,  the 
constitutional  disturbances  may  be  mild  or  severe.  Fever  may  exist, 
but  is  not  always  proportionate  to  the  extent  and  intensity  of  the 
inflammation.  The  pulse-rate  corresponds  to  the  degree  of  general 
intoxication,  and  is  to  be  regarded  as  a  more  reliable  indication  of 
systemic  infection  than  is  the  temperature.  The  menses  are  lessened 
or  suppressed.  The  uterine  discharge  is  at  first  serous,  later  seropuru- 
lent.  There  is  backache,  nausea,  a  sense  of  weight  in  the  pelvis,  rectal 
and  vesical  tenesmus,  and  pain  in  the  hypogastrium.  Bimanual  exami- 
nation reveals  a  uterus  tender  to  pressure,  not  perceptibly  increased 
in  size,  and  perfectly  movable.  The  external  os  may  be  slightly  patulous 
and  softer  than  normal.  Inspection  through  the  speculum  shows  a 
congestion  of  the  cervix  which  is  particularly  evident  at  the  external 
OS.  From  the  cervical  canal  flows  a  seropurulent  or  mucopurulent 
secretion;  it  is  seldom  clear,  serous,  or  mucous.  A  sound  introduced 
into  the  uterus  would  cause  some  pain  and  bleeding,  and  should  not 
be  used. 


422  INFLAMMATIONS  OF  THE  UTERUS 

Chronic  Endometritis. — For  practical  clinical  purposes  we  will  adopt 
a  classification  of  endometritis  based  upon  the  prominent  clinical 
sj'mptoms — hemorrhage,  leucorrhea,  and  pain,  and  will  speak  of 
hemorrhagic,  catarrhal,  and  dj^smenorrheic  endometritis. 

Clinical  Forms  of  Chronic  Entjometritis. — 1.  Hemorrhagic  endo- 
metritis is  characterized  by  an  unusual  loss  of  blood  during  and  some- 
times between  the  menstrual  periods.  Inasmuch  as  the  normal  limits  , 
of  menstruation  vary  widely,  it  is  difficult  to  fix  the  exact  limita- 
tions of  the  normal  and  the  abnormal  flow  of  blood.  The  normal 
limit  in  time  may  be  fixed  at  from  two  to  eight  days;  a  flow  continuing 
longer  than  eight  days  may  be  regarded  as  pathological.  The  average 
normal  quantity  of  menstrual  blood  is  six  to  eight  ounces.  Intermen- 
strual bleeding  is  always  pathological  and  demands  careful  inquiry 
into  the  cause.  It  is  unusual  for  endometritis  to  cause  intermenstrual 
bleeding.  Physical  exertion  may  excite  hemorrhage,  but  the  loss  of 
blood  is  never  considerable.  In  hemorrhagic  endometritis,  leucorrhea 
and  pain  may  be  present,  but  these  are  symptoms  of  less  prominence 
than  the  hemorrhage. 

2.  Catarrhal  endometritis  is  characterized  by  an  excessive  serous  or 
seropurulent  discharge  from  the  uterus.  The  amount  of  secretion  is 
not  proportionate  to  the  extent  and  degree  of  inflammatory  changes 
found  in  the  endometrium.  If  mucus  is  found  in  the  secretions,  the 
cervix  is  involved,  there  being  no  mucous  secretion  from  the  body 
of  the  uterus. 

To  differentiate  a  uterine  discharge  from  the  secretions  of  the  vulva 
and  vagina  the  Schultze  method  should  be  adopted.     (See  page  409.) 

Not  infrequently  women  complain  of  a  leucorrheal  discharge  during 
pregnancy  and  immediately  preceding  and  following  the  menstrual 
flow.  Such  are  within  normal  limits,  and  are  to  be  regarded  as  hyper- 
secretions of  the  congested  uterus,  vagina,  and  vulva. 

The  most  excessive  discharge  is  found  in  gonorrheal  endometritis. 
Nothing  can  be  ascertained  respecting  the  essential  cause  of  the  infection 
from  the  macroscopic  appearance  of  the  discharge.  Cover-slip  prepa- 
rations may  contain  the  gonococcus. 

3.  Dysmenorrheic  endometritis  is  characterized  by  painful  men- 
struation. Pain  is  little  to  be  relied  upon  in  the  diagnosis  of  endo- 
metritis. The  diagnosis  is  arrived  at  by  excluding  all  other  possible 
causes  of  pain.  The  pain  of  endometritis  is  described  as  being  of  a 
cramping,  bearing-down  character,  and  associated  with  a  feeling  of 
weight  in  the  pelvis.  However,  there  is  nothing  characteristic  in  the 
pain.  It  is  more  often  caused  by  such  complicating  lesions  as  salpingitis, 
ovaritis,  and  perimetritis. 

While  the  above-named  sjrmptoms — ^hemorrhage,  leucorrhea,  and 
pain — are  commonly  present  in  endometritis,  and  while  one  of  the  three 
symptoms  usually  dominates  and  justifies  the  terms  as  given  above,  it  is 
not  uncommon  for  endometritis  to  give  rise  to  no  symptoms.  Further- 
more, carcinoma,  sarcoma,  submucous  polyps,  and  retained  placental 
tissue  may  closely  simulate  endometritis  in  their  clinical  manifestations. 


ENDOMETRITIS 


423 


In  addition  to  the  above  clinical  forms  of  endometritis,  may  be  mentioned 
several  varieties  which  are  not  only  hemorrhagic,  catarrhal,  or  dys- 
menorrheic,  but  are  deserving  of  special  designation  because  of  some 
point  of  interest  relating  to  their  etiology,  time,  and  manner  of  occur- 
rence.   The  following  forms  are  ordinarily  recognized: 

4.  Tuberculous  endometritis  often  follows  a  primary  infection  of 
the  tubes.  When  tuberculous  salpingitis  is  recognized,  and  there 
develops  a  catarrhal  discharge  from  the  uterus,  the  extension  of  the 
tuberculous  process  to  the  endometrium  is  suspected.  Frequently 
there  is  amenorrhea.  Cover-slip  preparations  should  be  taken  from  the 
secretions  and  an  exploratory  curettage  may  be  made,  with  the  view 
of  finding  giant  cells,  tubercles,  and  tubercle  bacilli  in  the  scrapings. 


Fig.  297 


Uterus  from  a  patient  dying  on  the  tenth  day  from  a  mixed  infection — streptococci  and  colon 

bacilli.     (Jewett.) 


5.  Gonorrheal  endometritis  can  be  recognized  with  certainty  only  by 
finding  the  gonococcus  in  the  catarrhal  secretion.  It  is  not  alwaj's 
possible  to  demonstrate  the  presence  of  the  gonococcus  in  the  secretions  ; 
this  is  particularly  true  of  the  long-standing  cases.  When  a  leucorrheal 
discharge  appears  shortly  after  marriage,  and  when  in  addition  to 
leucorrhea  there  is  burning  on  urinating  and  infection  of  the  urethra 
and  glands  of  Bartholin,  little  doubt  can  be  entertained  as  to  the  natiu-e 
of  the  infection.  No  other  form  of  endometritis  causes  such  profuse 
discharge. 


424 


INFLAMMATIONS  OF  THE  UTERUS 


6.  Decidual  endometritis  is  a  term  applied  to  the  inflammation  of 
the  endometrium  of  p^egnanc3^  The  lesion  can  onl}^  be  suspected 
during  pregnancy.  A  positive  diagnosis  is  made  by  a  microscopic 
examination  of  the  decidua  after  the  expulsion  of  the  fetus.  Gonor- 
rhea is  the  usual  cause.  The  symptoms  are  hemorrhage,  which 
varies  in  amount  and  may  continue  throughout  pregnancy;  leucor- 
rhea  of  a  purulent  character,  less  often  serous,  sometimes  known 
as  hydrorrhea  gravidarum;  and  pain  of  a  cramping  or  bearing- 
down  character.  The  leucorrheal  secretion  ceases  in  the  latter  half 
of  pregnancy  when  the  decidua  reflexa  and  vera  unite.  Decidual 
endometritis  may  arise  prior  to  pregnancy,  and  is  one  of  the  potent 
causes  of  abortion. 

Fig.   298 


Uterus  from  patient  dj-ing  on  tenth  day  from  a  pure  streptococcic  infection.      (Jewett.) 

7.  Puerperal  endometritis  occms  in  the  puerperium  as  the  result  of 
instrumental  or  digital  infection.  It  is  not  infrequently  of  gonorrheal 
origin. 

8.  Postabortive  endometritis  follows  abortions,  usually  as  the  result 
of  instrumental  or  digital  infection. 

9.  Exfoliative  endometritis  (membranous  dysmenorrhea)  is  recognized 
clinically  by  the  periodic  expulsion  of  a  membrane  from  the  uterus, 


ENDOMETRITIS 


425 


either  as  a  cast  of  the  uterus  or  in  the  form  of  shreds.  Expulsion  of 
the  membrane  is  commonly  accompanied  by  severe  pain.  For  differen- 
tiation of  this  variety  from  other  discharged  membranes  see  page  142. 

10.  Senile  endometritis,  as  the  name  implies,  occurs  in  advanced 
years,  and  in  its  clinical  manifestations  (hemorrhage,  leucorrhea,  and 
pain)  may  closely  simulate  carcinoma.  There  is  no  satisfactory 
explanation  of  the  etiology  of  senile  endometritis. 

^Yhile  the  above  forms  are  commonly  recognized  without  difficulty, 
there  is  a  minority  of  cases  in  which  endometritis  is  only  distinguished 
by  anatomical  (gross  and  microscopic)  observations.  It  is  evident 
that  an  additional  classification,  based  upon  anatomical  findings,  will 
serve  when  the  clinical  signs  fail. 


Fig-  299 


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Hj-pertrophic  glandular  endometritis.    The  endometrium  is  thickened,  soft,  and  folded.     In  the 
cervix  are  several  distended  glands,  forming  a  cystic  protrusion. 


Anatomical  Classification  of  Endometritis. — According  to  Hitschman 
and  Alder,  chronic  endometritis  exists  only  in  the  interstitial  type, 
as  expressed  by  the  infiltration  of  the  interglandular  tissue  by  round 
cells,  and  that  the  plasma  cells  in  this  infiltrate  alone  are  characteristic. 
They  believe  that  the  hypertrophic  and  hyperplastic  glandular  types 
are  nothing  but  normal  premenstrual  findings.  The  author  believes 
that  their  findings  are  justified  to  a  degree,  but  prefers  to  hold  to  the 
anatomical  classification  of  Ruge  and  Veit,  which  is  here  presented. 


426  INFLAMMATIONS  OF  THE  UTERUS 

Macroscopic  Forms  of  Endometritis. — ^Macroscopic  forms  of  endo- 
metritis are  diagnosticated  after  the  uterus  is  removed  and  opened. 
Such-  findings  may  be  wholly  unsuspected  in  the  absence  of  all  clinical 
symptoms  of  endometritis.  The  following  forms  are  recognized  by 
the  unaided  eye: 

1.  Hyyertroyhic  endometritis,  in  which  the  endometrium  is  thickened 
and  soft. 

2.  Fungous  endometritis,  in  which  the  endometrium  is  throw^n  into 
folds  and  fungosities. 


,.x^'  I r'"'"'-  f" 


Fig.  300 


Normal  endometriura  of  a  young  woman.  The  surface  is  covered  with  a  single  layer  of  low  columnar 
epithelium.  The  glands  are  tubular,  wa^'y,  lined  with  columnar  epithelium  similar  to  that  of  the 
surface,  and  extend  to  the  musculature.  They  run  almost  at  right  angles  to  the  surface  of  the  endo- 
metrium. The  connective  tissue  is  embryonal  in  type,  and  contains  but  few  small  bloodvessels,  difficult 
to  demonstrate. 

3.  Villous  endometritis,  in  w^hich  the  surface  of  the  endometrium  is 
covered  with  shaggy  villosities. 

4.  Polyphoid  endometritis,  in  which  one  or  more  mucous  polyps 
project  from  the  endometrium. 

5.  Ulcerative  endometritis,  in  which  true  ulcers  are  formed  in  the 
endometrium.  These  ulcers  show  either  a  virulent  form  of  infection 
or  malignant  degeneration. 

6.  Pseudodiphtheritic  endometritis,  following  labor  and  abortion.  On 
the  surface  of  the  endometrium  is  a  necrotic  layer  formed  of  fibrin, 
degenerated  epithelium,  leucocytes,  blood,  and  microorganisms. 


ENDOMETRITIS  427 

Microscopic  Forms  of  Endometritis. — The  use  of  the  microscope  in 
the  diagnosis  of  endometritis,  already  alluded  to,  affords  the  only- 
means  of  making  a  positive  diagnosis  of  these  cases,  for  without  its 
aid  and  relying  upon  clinical  signs  and  symptoms,  not  only  may  the 
diagnosis  and  prognosis  be  faulty,  but  the  uterus  may  be  sacrificed  in 
the  treatment  of  what  appeared  to  be  a  malignant  growth.  Further- 
more, life  may  be  sacrificed  from  failure  to  remove  a  malignant  growth 
in  which  the  characteristic  symptoms  were  absent  or  suggestive  of 
endometritis.  In  order  that  no  serious  oversight  be  made,  it  is  important 
that  ■  a  systematic  microscopic  examination  be  made  of  all  uterine 
scrapings.  Two  general  forms  of  endometritis  are  recognized  by  the 
microscope — the  glandular  and  the  interstitial.  The  two  forms  are 
commonly  associated. 

1.  Glandular  endometritis  is  characterized  by  an  increase  in  size  or 
number,  or  both,  of  the  glandular  elements.  The  surface  of  the  endo- 
metrium is  thrown  into  irregular  elevations,  forming  folds,  fungosities, 
villi,  or  polyps. 

By  the  increase  in  size  and  number  of  the  secreting  epithelial  cells, 
the  glands  become  enlarged  and  irregular  in  their  course.  The  inter- 
glandular  spaces  are  decreased  proportionately  to  the  increase  in  the 
glandular  elements.  The  glands,  which  in  normal  conditions  rarely 
penetrate  into  the  musculature,  will,  when  hypertrophied,  penetrate 
this  region  to  a  limited  degree.  The  distortion  of  the  glands  may  be 
extreme.  In  longitudinal  sections  the  glands  may  appear  to  twist  like 
a  corkscrew.  The  inversion  and  eversion  of  the  glandular  epithelium 
may  give  a  serrated  appearance  to  the  gland. 

The  glands  are  not  only  increased  in  size  (hypertrophic  glandular 
endometritis),  but  may  be  increased  in  number  (hyperplastic  glandular 
endometritis).  The  increase  in  the  number  of  the  glands  is  a  result 
of  the  budding  from  preformed  glands  or  of  invaginations  of  the  surface 
epithelium.  If  we  fail  to  satisfactorily  classify  the  established  forms  of 
endometritis,  how  much  more  difficult  is  it  to  draw  the  line  sharply 
between  inflammatory  growths  of  the  endometrium  and  true  tumor 
formations. 

Are  we  to  recognize  a  benign  adenoma  of  the  uterus  ?  Are  the  mucous 
polyps  to  be  classified  as  newgrowths  or  as  polypoid  forms  of  endo- 
metritis? In  short,  is  it  possible  to  define  the  so-called  hyperplastic 
glandular  endometritis  from  benign  adenoma  of  the  endometrium? 

Referring  to  general  pathology,  we  are  unable  to  distinguish  hyper- 
plastic glandular  growths  of  inflammatory  origin  from  benign  adenomata. 
In  reviewing  the  opinions  of  a  number  of  authors,  it  becomes  evident 
that  to  separate  the  two  would  be  impossible,  and  to  admit  of  a 
connecting  link  between  the  two  lesions  is  admissible. 

Rindfleisch,  Chiari,  Weichselbaum,  and  Orth  favor  the  view  of 
simple  inflammatory  hyperplasia  to  the  exclusion  of  benign  adenoma 
of  mucous  surfaces.  Thoma,  Eppinger,  and  Ponfick  recognize  adenoma, 
while  others,  as  Van  Heukelom  and  Birch-Hirschfeld,  believe  in  the 
existence  of  a  connecting  link  between  these  lesions.     All  believe  in 


428  INFLAMMATIONS  OF  THE   UTERUS 

the  inflammatory  origin  of  mucous  polyps.  Polyps  of  inflammatory 
origin  are  found  in  the  stomach  by  Klebs.  Birch-Hirschfeld,  Petrow, 
and  Landel  describe  diffuse  and  circumscribed  growths  of  the  gastro- 
intestinal tract  due  to  catarrhal  inflammation.  By  a  careful  analysis 
of  their  reports,  it  is  evident  that  inflammatory  hyperplasia  of  mucous 
surfaces  merges  insensibly  into  tumor  growths,  both  benign  and  malig- 
nant. In  a  large  percentage  of  their  cases,  carcinoma  was  associated 
in  the  same  organ.  In  the  urinary  tract,  Stoerck,  Cahen,  Rehn,  and 
Kaufmann  recognize  papillomata  of  inflammatory  origin. 


Fig.  301 


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Normal  endometrium  of  a  woman  in  the  postclimacteric  period.     The  connective  tissue  is  more 
compact  and  mature;  the  glands  are  small  and  far  separated. 

Le  Count  believes  it  to  be  fully  demonstrated  that  there  exists  an 
imperceptible  transition  of  hyperplastic  processes  of  the  tubal  mucosa 
into  those  of  true  tumor  growths,  and  that  these  may  terminate  in 
the  production  of  benign  tumors. 

If  then  there  is  no  unanimity  of  opinion  among  general  pathologists, 
it  is  not  surprising  that  the  same  discrepancy  exists  among  gynecologists 
in  reference  to  similar  lesions  in  the  endometrium. 

We  find  Pozzi,  Olshausen,  Doderlein,  Gebhard,  and  Huge  failing 
to  recognize  benign  adenoma  of  the  uterus,  and  classifying  this  lesion 
as  inflammatory  hyperplasia,  reserving  the  term  adenoma  for  malignant 
glandular  growths. 

The  conclusion  is  that  the  two  lesions  cannot  be  clearly  differentiated; 


ENDOMETRITIS 


429 


that  a  connecting  link  exists  between  them.  Practically  speaking, 
all  are  agreed  that  there  exists  a  tendency  on  the  part  of  inflammatory 
glandular  growths  to  develop  into  benign  and  malignant  newgrowths, 


Fig.  302 


Fig.  303 


?> 


Fig.  304 


Fig.  305 


Fig.  306 


Fig.  307 


%-v' 


\    S^'^5!Sji£,v;y^fV- 


Fig.  309 


/.:C?^^J'S|v' 


Fig.  30S; 


•'0 


Explanatioa  of  scheme  of  gland  invagination.  Figs.  302  to  308  show  longitudinal  sections  of  invagi- 
nated  uterine  glands;  Fig.  303  to  309  show  cross-sections  of  the  same  gland.  The  glands  shown  in 
longitudinal  section  are  each  crossed  by  a  line  showing  the  plane  at  which  the  cross-sections  are  made. 
Fig.  302  shows  the  fundus  of  a  gland  invaginated  with  secondary  eversion.  Fig.  308  shows  intra- 
glandular  papillary  invagination  of  a  gland  epithelium  from  the  side  of  the  gland.  Fig.  304  shows 
simple  invagination  of  the  fundus  of  a  gland.  Fig.  306  shows  the  inner  and  out^r  segments  regular 
and  the  middle  segment  invaginated.     (Amann,  Mikroskopisch-Gynakologischen  Diagnostik.) 


430 


INFLAMMATIONS  OF  THE  UTERUS 


and  when  occurrring  in  old  age,   or  when  recurring  after  repeated 
curettage,  they  are  to  be  regarded  with  suspicion. 

The  buds  from  parent  glands  may  again  and  again  give  off  new 
glands.  We  speak  of  an  inverted  gland  when  processes  of  the  gland 
protrude  into  the  lumen;  of  an  everted  gland  when  the  processes 
protrude  from  the  lumen.  In  the  inverted  gland  cross-sections  will 
give  the  appearance  of  a  gland  within  a  gland.     (See  the  schematic 


Fig.  310 


m 


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Interstitial  endometritis.    The  glands  are  decreased  in  size  and  far  separated  by  mature  connective 

tissue. 


drawing,  page  429.)  More  or  less  connective  tissue  invariably  separates 
the  glands — a  fact  to  be  remembered  in  differentiating  this  condition 
from  malignant  adenoma.  In  rare  instances,  two  or  more  layers  of 
epithelium  are  found  on  the  surface  of  the  mucosa  or  in  the  glands. 
Many  layers  of  squamous  epithelium  have  been  observed.  Such 
proliferating  epithelium  is  always  superficial,  never  p'assing  beyond 
the  basement  epithelium,  as  in  malignant  glandular  growths. 

Spontaneous  healing  of  glandular  endometritis  is  possible  though 


ENDOMETRITIS  431 

not  probable.  At  the  time  of  the  menopause  the  hypertrophied  glands 
may  diminish  in  size  along  \\-ith  contraction  of  the  interstitial  connective 
tissue. 


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61     •" 

Tuberculous  glandular  endometritis.    Three  giant  cells  are  seen  in  the  section.    There  is  an  extensive 
roiind-cell  infiltration  and  degenerative  changes. 

2.  Interstitial  endometritis  is  characterized  by  a  hyperplasia  of 
the  interglandular  connective  tissue  at  the  expense  of  the  glandular 
elements.     Two  stages  are  recognized — the  acute  and  the  clu-onic. 


432  INFLAMMATIONS  OF  THE   UTERUS 

(a)  Acute  Interstitial  Endometritis. — ^x4.cute  interstitial  endometritis 
presents  a  small  round-cell  infiltration  in  the  stroma,  which  may  be 
diffuse  or  circumscribed.  The  bloodvessels  are  congested  and  a  serous 
or  serosanguineous  exudate  permeates  the  connective-tissue  spaces. 
The  glands  are  crowded  apart  by  the  widening  of  the  interglandular 
spaces.  They  are  irregularly  compressed,  causing  them  to  be  greatly 
distorted.  Healing  may  be  perfect  from  absorption  of  the  exudate, 
or  the  acute  stage  may  gradually  merge  into  the  chronic. 

Acute  senile  endometritis  is  described  by  Dunning,  who  presents 
the  following  summary  of  the  anatomical  findings:  "The  endometrium 
is  thickened,  the  free  surface  is  devoid  of  an  epithelial  covering;  there 
is  an  increase  in  the  vascularity  with  a  peculiar  arrangement  of  the 
small  bloodvessels;  there  is  a  small  round-cell  infiltration;  the  glandular 
elements  are  diminished;  the  coats  of  the  arteries  of  the  muscularis' 
are  degenerated."  The  presence  of  diseased  appendages  in  both  cases 
reported  by  Dunning  and  of  a  mild  form  of  pelvic  peritonitis  in  one 
case  seems  to  indicate  that  the  inflammation  tends  to  extend  beyond 
the  limits  of  the  uterus. 

(h)  Chronic  Interstitial  Endometritis. — Newly  formed  connective 
tissue  separates  the  glands.  The  glands  are  irregularly  compressed 
and  may  suffer  pressure  atrophy.  In  place  of  the  embryonal  connective 
tissue  normally  found  in  the  endometrium,  there  is  matured  fibrous 
tissue,  which  first  thickens  the  endometrium  and  later  contracts,  result- 
ing in  a  diffuse  or  localized  atrophy  of  the  mucosa.  The  surface  of 
the  endometrium  becomes  irregular.  Retention  cysts  may  appear  in  the 
endometrium  from  an  obstruction  at  the  outlet  of  the  glands,  causing 
the  glands  to  distend  with  the  secretions.  In  direct  proportion  to  the 
distention  of  the  glands,  the  epithelial  cells  lining  them  are  compressed 
and  may  be  quite  flattened.  The  interglandular  spaces  may  be  greatly 
narrowed.  When  retention  cysts  are  numerous,  the  term  cystic  glandular 
endometritis  or  cystic  interstitial  endometritis  is  applied. 

When  the  connective-tissue  spaces  are  filled  and  distended  by  a 
serous  or  serosanguineous  exudate  the  term  exudative  interstitial 
endometritis  is  applied.  Thus  there  may  be  a  combination  of  these 
forms,  and  one  may  speak  of  a  hj'pertrophic  and  hyperplastic  cystic, 
exudative,  glandular,  and  interstitial  endometritis — a  rather  formidable 
name,  but  nevertheless  suggestive. 

Combinations  of  the  glandular  and  interstitial  forms  of  endometritis 
are  the  rule.  It  is  unusual  for  either  form  to  exist  alone.  Rarely  are 
the  glandular  and  interglandular  tissues  uniformly  involved  (diffuse 
endometritis) . 

The  diagnosis  of  uterine  scrapings  in  endometritis  is  preeminently 
satisfactory  and  reliable.  The  loose  texture  of  the  endometrium 
permits  easy  removal  of  the  mucosa  by  the  sharp  curet.  It  is  true  that 
the  structures  composing  the  mucosa  are  more  or  less  distorted  in  the 
scrapings,  and  that  the  deep  layers  of  the  endometrium  are  seldom 
found  in  the  removed  particles.  When  it  is  considered  that  the  upper 
strata  may  show  glandular  ^changes  and  the  lower  strata  interstitial 


ABSCESS  OF  THE   UTERUS 


433 


changes,  or  the  upper  strata  show  an  inflammatory  reaction  and  the 
lower  strata  maHgnant  degeneration,  it  is  evident  that  the  microscopic 
examination  of  scrapings  is  not  always  reliable. 

Little  can  be  definitely  learned  from  the  naked-eye  appearance  of 
the  scrapings.  Large  friable  masses,  homogeneous  in  appearance,  of  a 
pale  gray  color,  suggest  malignancy.  In  cystic  formations  the  open 
spaces  may  be  detected  by  the  naked  eye.  In  general  it  may  be 
said  that  little  that  is  positive  can  be  learned  from  a  macroscopic 
examination  of  particles  removed  from  the  uterus  by  the  curet. 


CHRONIC  METRITIS 


Fig.  312 


Endometritis  can  scarcely  exist 
without  more  or  less  involvement 
of  the  uterine  musculature.  In 
acute  affections  the  muscularis  is 
congested  and  the  connective-tissue 
spaces  are  filled  with  a  serous 
exudate  and  a  round-cell  infiltra- 
tion. Abscesses  may  develop  in 
the  connective-tissue  spaces  and 
infected  thrombi  may  form  in  the 
blood-spaces. 

In  the  chronic  stage  there  is  a 
development  of  connective  tissue 
between  the  muscle  fibers.  As  the 
connective  tissue  forms  and  con- 
tracts the  muscle  fibers  atrophy, 
and  through  this  process  the  uterus 
becomes  very  firm. 

The  diagnosis  is  based  upon  the 
uniform  enlargement  of  the  uterus 
and  upon  the  change  in  its  con- 
sistency. In  the  chronic  stage  there 
may  be  no  tenderness  on  pressure. 

Chronic  metritis  may  be  regarded 
as  a  clinical  term  signifying  a 
uterus  that  is  uniformly  enlarged, 
firm  in  consistency,  and  one  which 
has  lost  its  normal  flexibility. 

Chronic  metritis  is  to  be  diagnosticated  from  interstitial  fibroids 
(See  Chapter  XXVI.) 


Chronic  metritic  uterus  (natural  size)  re- 
moved from  a  patient,  aged  fifty-two  years, 
who  had  had  nine  children,  but  no  miscar- 
riages. The  symptoms  were  menorrhagia  and 
metrorrhagia  since  last  confinement,  nineteen 
years  ago.  The  last  few  weeks  the  hemorrhage 
had  been  almost  continuous.  Note  the  thick- 
ness of  the  endometrium.  a,  endometrium. 
(Donald.) 


ABSCESS  OF  THE  UTERUS 

Little  has  been  written  on  abscesses  of  the  uterine  wall.  Barrows 
collected  forty-one  cases  from  the  literature  and  adds  seven  of  his 
own.     Doubtless  many  cases  escape  recognition.     Some  open  spon- 

28 


434  INFLAMMATIONS  OF  THE   UTERUS 

taneously  into  the  uterine  cavity  and  are  thought  to  be  pus-tubes; 
others  escape  into  the  pelvic  cavity  or  between  the  layers  of  the  broad 
ligaments,  and  again  it  is  highly  probable  that  such  abscesses  are 
inadvertently  opened  by  the  curet.  The  majority  follows  labor  and 
abortion;  a  few  are  of  gonorrheal  origin.  The  greatest  number  of  these 
abscesses  lie  in  the  anterior  wall  of  the  uterus. 

The  treatment  is  preeminently  conservative  throughout  the  acute 
stage.  Rest  in  bed,  ice  applied  to  the  abdomen,  and  sedatives  for 
relief  from  pain  when  required,  will  carry  the  patient  on  to  the  subacute 
or  chronic  stage,  when  drainage  should  be  established.  Inasmuch  as 
the  abscesses  are  commonly  located  in  the  anterior  wall  of  the  uterus 
the  usual  procedure  is  to  drain  through  a  suprapubic  incision.  In 
exceptional  cases  vaginal  drainage  through  the  cul-de-sac  will  sufl&ce. 


TREATMENT  OF  INFLAMMATIONS  OF  THE  UTERUS 

In  the  discussion  of  the  treatment  of  inflammations  of  the  uterus 
the  subject  will  be  divided  into  the  acute  and  chronic  stages. 

Acute  Metritis. — The  most  important  consideration  is  the  prevention 
of  acute  infections  of  the  uterus. 

Prophylaxis. — Many  of  the  causes  of  acute  metritis  are  preventable, 
at  least  to  a  large  degree.  For  a  discussion  of  these  causes  see  page 
390.  Two  etiological  factors  stand  foremost  in  point  of  frequency  and 
gravity,  i.  e.,  puerperal  infection  following  labor  and  abortion,  and 
gonorrhea.  Only  an  outline  will  be  given  of  the  means  employed 
in  preventing  these  forms  of  infection.  For  further  discussion  see 
standard  works  on  obstetrics. 

Prevention  of  Puerperal  Infection. — 1.  Avoid  all  unnecessary  hasten- 
ing of  the  second  stage  of  labor. 

2.  Limit  to  a  minimum  the  extent  of  puerperal  wounds. 

3.  Repair  all  lacerated  wounds  of  the  perineum  at  the  completion 
of  labor. 

4.  Limit  to  a  minimum  the  number  of  vaginal  examinations. 

5.  Practice  scrupulous  asepsis  before,  during,  and  after  labor. 

6.  Avoid  prophylactic  douches,  unless  especially  indicated  and 
directed. 

7.  Regard  generative  tract  after  labor  as  the  noli  me  tangere,  save 
in  event  of  an  emergency. 

8.  Completely  remove  all  secundines  from  the  uterus. 

Prevention  of  Gonorrheal  Infection. — 1.  Educate  the  profession  and 
laity  to  a  keen  appreciation  of  the  serious  consequences  of  the  disease. 

2.  Withhold  sanction  to  marry  or  to  resume  sexual  relations  until, 
by  repeated  bacteriological  examinations,  the  gonococci  are  known  to 
be  absent. 

3.  Avoid  instrumental  and  digital  manipulations  within  the  urethra 
and  uterine  canal  throughout  the  acute  stage. 

4.  Use  clean  hands  and  instruments  in  all  examinations. 


TREATMENT  OF  INFLAMMATIONS  OF  THE  UTERUS        435 

5.  To  depend  upon  medical  regulation  and  supervision  of  prosti- 
tution is  inadvisable,  inadequate,  and  promotive  of  a  false  sense  of 
security  from  infection. 

There  are  many  predisposing  factors  to  acute  metritis  which  deserve 
consideration,  such  as  constipation,  tight-lacing,  faulty  elimination, 
excessive  venery,  uterine  displacements,  and  constitutional  diseases. 
These  should  be  eliminated;  the  remedies  are  readil}'  suggested. 

Conservative  Treatment.— The  management  of  acute  metritis  must  be 
preeminently  conservative.  Radical  measures  have  been  responsible  for 
much  harm.  It  may  be  said,  without  qualification,  that  there  is  but 
one  indication  for  surgical  interference  in  the  acute  stage  of  metritis, 
and  that  is  the  presence  of  placental  tissue  retained  within  the  uterus. 
Under  all  other  conditions  no  operative  measures  should  be  entertained. 

Untimely  surgical  interference  is  responsible  for  the  spread  of  infec- 
tion. An  endocervicitis  is  spread  to  the  body  of  the  uterus  and  an 
endometritis  is  made  to  involve  the  appendages.  Every  possible 
precaution  should  be  taken  to  avoid  disturbing  the  infection.  Hence 
rest  is  of  prime  importance. 

Rest. — Throughout  the  acute  stage  of  the  infection  the  patient 
should  be  confined  to  her  bed.  Instrumental  and  digital  examinations 
should  be  made  only  when  imperative. 

Cleanliness.— Cieanlmess  should  be  maintained  by  means  of  the 
vaginal  douche.  When  the  discharge  has  a  foul  odor,  formalin  douches, 
in  the  proportion  of  1  to  2000,  will  be  found  effective.  Throughout 
the  acute  stage  the  douches  should  be  given  under  low  pressure,  with 
the  patient  in  the  recumbent  position.  The  temperature  of  the  douche 
should  be  110°,  and  the  duration  about  ten  to  fifteen  minutes. 

Depletion  of  the  Congested  Tissues.  —  Long-continued  hot  vaginal 
douches,  together  with  glycerin  and  ichthyol  tampons,  will  deplete 
the  congested  tissues  and  shorten  the  acute  stage  of  the  inflammation. 
For  a  full  discussion  of  the  application  of  vaginal  douches  see  page  196, 
and  of  tampons  see  page  213. 

No  intra-uterine  applications  are  to  be  made  in  the  acute  stage, 
hence  intra-uterine  irrigations,  injections,  swabs,  and  packs  are  pro- 
scribed. The  sole  exception  to  this  rule  is  that,  subsequent  to  the 
removal  of  retained  placental  tissue,  the  uterine  cavity  should  be 
irrigated  with  sterile  normal  salt  solution. 

Relief  from  Pain. — For  relief  from  pain,  cold  applications  may  be 
placed  to  the  hypogastrium.  Here  the  ice-bag  not  only  relieves  pain, 
but  is  a  valuable  aid  in  reducing  the  inflammatory  reaction. 

The  bowels  should  be  kept  freely  open  by  the  use  of  saline  laxatives. 

The  diet  should  be  light  and  nutritious. 

The  fluidextract  of  ergot  in  10-minim  doses  or  ergotol  in  5-  to  10- 
minim  doses  should  be  given  three  or  four  times  a  day  in  the  puerperal 
cases,  for  the  purpose  of  contracting  the  uterus  and  limiting  the  lymph 
and  blood  avenues  for  the  conveyance  of  infection. 

Stimulation. — Stimulation  is  required  when  there  is  depression  from 
toxic  absorption.     For  this  purpose  whisky  or  brandy  may  be  given 


436  INFLAMMATIOXS  OF   THE   UTERUS 

freely;  strychnine  may  be  given  in  doses  of  ^w  to  iro  grain  two  to  six 
times  a  day,  and  normal  salt  solution  may  be  given  by  the  bowel  or 
under  the  skin  to  the  extent  of  a  pint  one  to  four  times  a  day.  (See 
chapter  on  Hydrotherapy.) 

The  Surgical  Treatment  of  Puerperal  Infections. — If  we  are  to  intel- 
ligently apply  operative  measures  in  puerperal  infections,  we  must 
know  the  nature  of  the  infecting  microorganisms,  and  also  the  limit 
to  which  the  infection  has  extended.  ^lore  than  this,  we  should  be 
possessed  of  means  of  determining  the  ultimate  outcome  of  a  given 
case,  with  or  without  surgical  intervention,  if  we  are  to  intelligently 
choose  between  tentative  treatment  and  operative  interference. 
We  cannot  as  yet  rely  upon  our  clinical  and  laboratory  guides  in 
determining  these  factors.  According  to  Sachs  the  prognosis  is 
dependent  upon  three  factors,  i.  e.,  the  resistance  of  the  individual, 
the  location  of  the  infection,  and  the  character  of  the  infecting  micro- 
organism. 

Removal  of  Retained  Placenta. — Placental  rests  should  be  removed 
with  the  least  possible  injury  to  the  uterus,  and  at  the  earliest  possible 
moment,  for  the  reason  that  placental  remains  may  harbor  sapro- 
phytes which  in  time  may  become  virulent.  This  is  best  done  with 
the  fingers,  and  if  this  is  impossible  the  Emmet  curet  forceps  or 
placental  forceps  should  be  used,  but  the  curet  should  never  be  used. 
Retained  membranes  can  be  safely  left  to  nature. 

Curettage. — Curettage  of  the  infected  uterus  is  universally  condemned. 
It  is  generally  conceded  that  a  thorough  curettage  of  the  puerperal 
uterus  is  a  difficult  and  dangerous  task.  "The  curet  is  blind,"  and  is 
capable  of  much  mischief  in  the  hands  of  the  skilled  as  well  as  the 
novice.  In  the  presence  of  virulent  streptococci  the  danger  is  great- 
est because  the  inevitable  wounds  created  b}'  the  curet  will  almost 
certainly  be  infected,  and  then  follows  an  extension  of  the  infection 
to  the  uterine  musculature,  pelvic  connective  tissue,  appendages, 
peritoneum,  and  the  general  circulation  of  the  blood. 

Hysterectomy. — Inasmuch  as  there  are  no  certain  means  of  deter- 
mining the  extent  of  an  infection,  it  is  impossible  to  judge  with  cer- 
tainty whether  a  hysterectomy  will  fully  eradicate  the  infection.  It 
is  not  known  with  certainty  what  the  ultimate  outcome  of  a  uterine 
infection  will  be.  Clinical  signs  and  laboratory  guides  fail  in  this 
regard,  and  one  is  therefore  at  a  loss  to  recognize  the  indication 
for  hysterectomy  in  a  puerperal  infection.  The  infected  uterus  should 
be  removed  when  it  has  been  perforated  or  torn,  when  sloughing 
fibroids  are  inaccessible  to  myomectomy,  when  multiple  abscesses  of 
the  uterine  wall  are  recognized,  and  when  the  infected  placenta  cannot 
be  removed  through  the  natural  channel.  In  these  cases  hysterectomy 
may  be  permissible,  provided  the  infection  has  not  become  general  and 
the  strength  of  the  patient  will  permit.  To  anticipate  a  generalized 
infection  by  extirpating  the  uterus  when  the  above  conditions  do  not 
prevail  is  not  justified  by  present  knowledge  and  experience. 


TREATMENT  OF  INFLAMMATIONS  OF  THE  UTERUS        437 

Ligation  of  the  Pelvic  Veins  in  Puerperal  Thrombophlebitis. — Fre- 
quency.— The  frequency  of  puerperal  thrombophlebitis  is  estimated  at 
approximately  30  to  55  per  cent,  of  all  fatal  cases  of  puerperal  sepsis. 
The  veins  primarily  involved  are  the  uterine  and  ovarian  or  spermatic. 

For  years  the  aural  surgeons  were  ligating  the  jugular  vein  to  check 
the  advance  of  infected  thrombi,  when  W.  A.  Freund,  in  1897,  ligated 
the  spermatic  veins  of  two  cases  of  puerperal  thrombophlebitis,  but 
without  success.  Five  years  later  Trendelenburg  operated  on  five 
cases,  with  one  recovery.  Since  then  Fromme,  D.  Cuff,  Latzke, 
Whitridge  Williams,  Lenhartz,  Opitz,  Osterlow,  Vineberg,  Miller, 
Huggins,  and  others  have  reported  cases. 

Time  of  Operation. — ^We  are  admonished  not  to  operate  in  the  acute 
stage  of  the  infection.  Trendelenburg  and  Bucura  say  to  operate  after 
the  fourth  chill.  It  is  questionable  if  this  is  a  safe  rule  of  practice, 
inasmuch  as  many  cases  are  known  to  recover  without  operation  after 
a  dozen  or  more  chills. 

Contra-indications. — The  operation  is  not  advisable  when  metastatic 
abscesses  are  recognized,  when  pus  has  accumulated  in  the  pelvis, 
and  when  there  are  distinct  evidences  of  lymphatic  invasion. 
Pneumonia  and  endocarditis  are  placed  as  contra-indications  to  the 
operation,  while  pleurisy  and  lung  infarcts  are  not  necessarily  contra- 
indications. 

Technic  of  Operation. — The  thrombosed  veins  have  been  approached 
by  three  routes:  the  vaginal,  the  extraperitoneal,  and  the  intraperito- 
neal. The  first  and  second  procedures  have  not  been  generally  adopted 
for  the  reason  that  the  veins  of  the  pelvis  and  higher  up  in  the  abdomen 
cannot  be  under  direct  inspection. 

The  technic  of  the  intraperitoneal  route  is  briefly  as  follows:  The 
abdomen  is  opened  in  the  median  line.  The  uterus  and  its  appendages 
are  inspected.  Next  the  broad  ligaments  are  inspected  and  palpated, 
with  special  reference  to  the  course  of  the  uterine  and  ovarian  veins. 
If  the  broad  ligaments  are  found  to  be  thickened  along  the  course  of 
these  veins  the  existence  of  thrombosis  is  assumed.  The  veins  are  then 
palpated  along  their  course  to  a  point  above  the  thrombus;  here  the 
peritoneum  is  incised  and  a  ligature  is  passed  about  the  veins  by  means 
of  an  aneurysm  needle.  Ligature  of  the  ovarian  veins  may  be  made 
as  high  as  the  vena  cava  on  the  right  side  and  to  the  point  of  union  with 
the  renal  veins  on  the  left  side.  When  the  internal  iliac  vein  is  involved, 
it  should  be  ligated  near  to  its  juncture  with  the  external  iliac  vein. 
If  a  median  iliac  vein  exists  this  should  be  ligated  at  its  juncture  with 
the  external  iliac  trunk.  Lea  recommends  the  ligature  of  both  sides 
in  every  case  because  of  the  free  anastomosis.  The  more  acute  the 
infection  the  more  extensive  the  ligations.  Care  must  be  taken  to 
prevent  ligature  of  the  ureters  and  lumbosacral  cord. 

After  such  extensive  ligations  of  the  veins  the  pelvic  organs  and 
vulva  become  edematous,  but  this  is  soon  remedied  by  the  establishment 
of  collateral  circulation.  When  the  thrombus  has  developed  into  an 
abscess  it  is  advisable  to  dissect  out  the  vein  with  a  thermocautery. 


438  INFLAMMATIONS  OF  THE  UTERUS 

My  personal  belief  is  that  the  Trendelenburg  operation  is  a  ques- 
tionable procedure  because  of  the  difficulties  encountered  in  the 
making  of  an  accurate  diagnosis  and  the  many  dangers  attending  the 
operation. 

Chronic  Metritis. — In  the  chronic  stage  of  metritis  the  results  of 
treatment  are  uncertain.    This  is  particularly  true  of  gonorrheal  metritis. 

Much  may  be  accomplished  in  alleviating  symptoms,  but  it  is  difficult 
to  restore  the  diseased  tissues  to  their  normal  state.  There  is  apparently 
no  disease  of  the  uterus  more  difficult  to  cure  than  chronic  metritis, 
because  of  the  persistence  of  the  infecting  microorganisms,  notably  the 
gonococcus,  and  the  tissue  changes  which  are  the  result  of  infection. 

There  are  many  cases  of  ''unsuspected  metritis,"  and  by  this  term 
is  meant  the  presence  of  an  inflammatory  lesion  in  the  uterus  without 
physical  or  psychic  functional  disturbances.  Menge  divides  these 
cases  of  unsuspected  metritis  into  two  classes:  (1)  Those  in  which  the 
psychical  condition  is  predominant,  and  (2)  those  in  which  the  psychical 
condition  is  normal. 

Neither  of  these  two  classes  demands  local  treatment.  To  instigate 
local  treatments  could  only  serve  to  centre  the  attention  of  the  patient 
upon  the  genital  organs  and  give  rise  to  grave  psychic  disturbances. 
The  treatment  in  such  cases  is  purely  hygienic  and  psychic. 

Chronic  metritis  is  usually  associated  with  psychic  disorders,  notably 
hysteria  and  neurasthenia.  Psychic  disorders  demand  psychic  treat- 
ment; hence  it  follows  that  psychotherapy  is  an  essential  part  of  the 
rational  treatment  of  such  cases. 

General  Treatment. — The  diet  should  be  nutritious  but  light.  The 
bowels  should  be  carefully  regulated.  Systematic  daily  outdoor 
exercises  are  of  the  highest  value.  These  regulations,  together  with 
psychotherapy,  should  be  adopted  whether  local  treatments  are  or  are 
not  employed. 

For  the  control  of  hemorrhage  due  to  endometritis  general  medication 
may  suffice,  but  more  often  the  remedies  must  be  supported  by  local 
measures.  These  remedies  are  ergot,  stypticin,  hydrastis,  styptol, 
and  adrenalin.  Rest  must  be  enjoined  along  with  the  administration 
of  these  drugs. 

Local  Treatment. — Whenever  local  disturbances  arise  as  the  result 
of  chronic  metritis,  local  treatment  is  indicated. 

Curettage. — In  former  years  the  curet  was  universally  adopted  as  a 
means  of  treatment  of  chronic  metritis.  It  is  certain  that  its  general 
use  has  led  to  much  abuse  in  the  hands  of  the  general  practitioner  and 
specialist. 

Olshausen  says  "that  abrasio  mucosae  is  not  every  man's  task." 
The  truth  of  this  statement  is  verified  by  repeated  observations  in 
which  the  curet  has  perforated  the  uterus,  removed  the  mucosa  to  an 
extent  that  leads  to  partial  or  complete  atresia  of  the  cervical  canal 
and  cavity  of  the  uterus,  and  again  has  failed  to  remove  all  of  the 
diseased  endometrium.  The  curet  should  never  be  used  in  the  presence 
of  a  purulent  leucorrhea.     Indeed,  the  only  indication  for  the  use  of 


TREATMENT  OF  INFLAMMATIONS  OF   THE   UTERUS        439 

the  curet  in  chronic  metritis  is  to  control  hemorrhage.     As  indicated 
abovCj  the  curet  has  no  place  in  the  treatment  of  acute  metritis. 

When,  therefore,  we  compare  the  indiscriminate  use  of  the  curet 
by  the  profession  with  the  limited  restrictions  as  above  recorded  we 
are  impressed  with  the  importance  of  giving  serious  consideration  to 
the  subject. 

The  indications,  contra-indications,  dangers,  and  technic  of  curettage 
are  given  in  Chapter  VII. 

In  event  of  perforation  of  the  uterus  by  the  cm-et  no  attempt  to 
repair  the  injury  should  be  made  unless  there  is  infection  within  the 
uterine  cavity.  If  infection  is  present  the  author  is  of  the  opinion 
that  the  safest  procedure  would  be  to  remove  the  uterus  and  establish 
drainage. 

The  patient  should  rest  in  bed  one  week  after  curettage.  Hot  vaginal 
douches,  glycerin  and  ichthyol  tampons,  careful  regulation  of  the  diet, 
of  the  bowels,  and  of  exercise  should  be  directed  for  a  variable  period 
thereafter,  if  good  and  permanent  results  are  to  be  obtained. 

Medicinal  Local  Treatment. — ^Medicinal  applications  are  made  directly 
to  the  endometrium  and  indirectly  to  the  uterus  by  means  of  vaginal 
packs,  douches,  and  suppositories. 

Douches. — ^Antiseptic  douches  have  no  more  effect  upon  an  infected 
uterus  than  does  sterile  water  of  like  amount  and  temperature.  The 
effect  is  detergent  and  thermic  rather  than  antiseptic,  for  the  reason 
that  the  antiseptic  solution  does  not  reach  the  infected  tissues.  Astrin- 
gent douches  are  likewise  deceptive  in  their  action,  inasmuch  as  only 
superficial  tissues  can  be  affected  by  the  astringent  properties  of  the 
douche. 

Caustic  Applications.— Csiustic  applications  to  the  endometrium 
are  applied  for  the  purpose  of  destroying  the  diseased  endometrium. 
Some  are  inert,  some  injurious,  and  only  one,  in  the  author's  judgment, 
is  preeminently  satisfactory'.  Tincture  of  iodine  is  inefficient,  and 
the  same  may  be  said  of  the  sesqui chloride  of  iron;  nitrate  of  silver  is 
liable  to  cause  stenosis;  the  sulphate  of  copper  produces  uterine  colic 
and  has  not  afforded  satisfactory  results.  Formalin  in  full  strength 
is  an  excellent  antiseptic  application.  It  penetrates  deeply,  but  is  not 
knoTVTi  to  cause  stenosis.  Formalin  is  applied  by  means  of  a  swab. 
Intra-uterine  injections  are  not  advised  for  fear  of  injecting  the  solution 
through  the  Fallopian  tubes,  and  because  of  the  consequent  danger  of 
poisoning. 

Technic  of  Sicabbing. — In  swabbing  the  uterus  it  is  essential  that 
the  cervix  be  well  dilated  to  allow  the  application  to  all  parts  of  the 
endometrium.  The  cervix  should  be  exposed,  preferably  by  a  hanging 
speculum  overriding  the  perineum,  and  a  narrow  blade  retractor  for 
the  anterior  wall  of  the  vagina.  The  anterior  lip  of  the  cervix  is  grasped 
by  a  single  prong  tenaculum  forceps,  by  which  gentle  but  firm  traction 
is  made  upon  the  cervix. 

The  swab  is  passed  through  the  dilated  cervix,  but  not  without 
knowledge  of  the  size  and  position  of  the  uterus  previously  gained 


440 


INFLAMMATIONS  OF  THE  UTERUS 


through  a  bimanual  examination.    This  precaution  is  taken  to  prevent 
the  possible  puncture  of  the  uterus. 

The  author  generally  uses  wooden  applicators  accurately  wound 
with  cotton.  They  are  recommended  because  they  can  be  sterilized, 
together  with  the  towels,  sheets,  and  gauze,  and  their  cheapness  permits 
of  using  them  but  once.  A  thin  film  of  cotton  should  be  wrapped  about 
the  end  of  the  applicator  for  a  distance  of  at  least  four  inches,  in  order 
that  the  cotton  may  not  be  lost  in  the  uterine  cavity.  The  objection 
to  the  wooden  applicator  is  that  it  cannot  be  bent  to  conform  to  the 

Fig.  313 


Intra-uterine  injection  of  zinc  chloride.  Cervix  exposed  by  a  retractor  held  by  an  assistant.  Cervix 
grasped  by  a  tenaculum  forceps.  Zinc  chloride  injected  through  a  tonsillar  syringe  equipped  with  an 
extended  metallic  nozzle. 


curve  of  the  uterine  canal.  Three  applicators  are  commonly  used: 
one  dry  for  the  purpose  of  removing  the  mucus  within  the  cervix  and 
two  for  the  application  of  formalin.  A  pledget  of  cotton  or  strip  of 
gauze  should  be  placed  behind  the  cervix  before  applying  the  fqrrnalin, 
to  protect  the  vaginal  wall. 

To  give  time  for  the  formation  of  a  slough,  for  the  discharge  of 
the  slough,  and  for  the  regeneration  of  the  mucosa,  these  appli- 
cations should  not  be  repeated  at  short  intervals.  Menge  advises  a 
second  application  in  five  to  eight  days  if  improvement  in  the  symp- 


TREATMENT  OF  INFLAMMATIONS  OF  THE   UTERUS       441 

toms  does  not  follow.  As  a  rule,  but  a  single  application  is  required 
for  postpartum  and  postabortive  infections,  but  in  gonorrheal  infection 
several  applications  may  be  required. 

Only  in  the  chronic  stages  of  inflammation  is  this  treatment  indicated. 
INIenge  places  the  time  limit  at  not  less  than  three  months  after  the 
initial   infection. 

Zinc  chloride  solution  is  an  excellent  escharotic,  and  should  replace 
the  curet  in  gonorrheal  endometritis.  It  will  as  effectively  destroy  the 
diseased  endometrium  as  the  curet,  and  does  not  create  wounds  by 
which  the  infection  can  spread. 

The  technic  of  applying  zinc  chloride  to  the  endometrium  is  as  follows: 
If  the  patient  is  under  an  anesthetic  the  cervix  is  dilated  and  a  30  per 
cent,  solution  of  zinc  chloride  is  applied  to  the  endometrium  on  a 
swab.  A  second  swab  should  be  used,  to  make  sure  that  the  work  is 
done  thoroughly.  If  no  anesthetic  is  used,  the  author  generally  injects 
into  the  cavity  of  the  uterus  a  5  per  cent,  solution  by  means  of  a 
small  sjTinge  with  a  long  curved  metallic  nozzle.  These  applications 
may  be  repeated  from  tliree  to  six  times  in  the  course  of  the  following 
six  to  ten  weeks.  Caution  must  be  exercised  for  fear  of  creating  too 
deep  a  destruction  of  the  tissues. 

Operative  Treatment. — Amimtation  of  the  Cermx. — Martin,  of  Griefs- 
wald,  recommends  the  amputation  of  one  or  both  lips  of  the. cervix 
in  extreme  cases  of  chronic  metritis.  When  preceded  by  curettage, 
amputation  of  the  cervix  often  improves  the  condition  of  the  uterus. 

Subtotal  Hysterectomy. — In  women  who  have  not  yet  reached  the 
climacterium,  an  effort  should  be  made  to  save  a  part  of  the  body  of 
the  uterus  so  as  to  preserve  the  menstrual  function.  For  this  purpose 
the  subtotal  hysterectomy  devised  by  Bruettner  is  advised.  Following 
is  the  technic  of  the  operation: 

Step  1. — Median  abdominal  incision  or  the  transverse  incision  of 
Pfannenstiel. 

Step  2.  —  Careful  inspection  of  the  pelvic  organs,  with  special 
reference  to  the  ovaries.  If  part  or  all  of  the  oA^aries  can  be  safely 
preserved,  a  cuneiform  piece  is  excised  from  the  fundus,  avoiding,  if 
possible,  the  insertion  of  the  round  ligaments.  This  incision  is  prolonged 
on  either  side  into  the  broad  ligaments  (Fig.  314). 

Step  3. — ^The  wedge-shape  portion  of  the  fundus  is  grasped  by 
tenaculum  forceps  and  removed  with  scissors.  The  uterine  arteries 
are  ligated  on  either  side  (Fig.  315). 

Step  4. — The  uterine  wound  is  closed  by  two  or  three  rows  of  catgut 
sutures.  The  broad  ligaments  are  carefully  stitched  with  a  continuous 
catgut  suture.  This  leaves  a  small  uterus,  with  little  or  no  disturbance 
of  the  anatomical  relations  (Fig.  316). 

Hysterectomy. — Hysterectomy  is  indicated  in  extreme  cases  of  chronic 
metritis  when  general  and  local  conservative  measures  fail  to  relieve 
distressing  symptoms.  When  the  appendages  are  removed  such  a  uterus 
should  be  removed  with  them.  In  tuberculous  metritis,  not  only  the 
uterus  but  its  appendages  should  be  removed  by  way  of  the  abdomen. 


442 


INFLAMMATIONS  OF  THE   UTERUS 


Treatment  of  Endocervicitis. — The  mucosa  lining  the  cervical  canal 
may  be  infected  independently  of  the  body  of  the  uterus.  This  is 
notably  true  of  gonorrheal  infections. 

In  the  treatment  of  endocervicitis,  swabbing  with  caustics  and 
antiseptics  have  long  been  practised  and  are  often  of  great  value. 
This  may  be  accomplished  without  anesthesia  if  the  cervical  canal  is 
patent  to  the  ordinary  swab;  if  not,  an  anesthetic  may  be  required  to 
dilate  the  cervix. 

Fig.  314 


Outlines  of  cuneiform  incision  in  the  fundus. 


Fig.  315 


Wedge-shaped  portion  removed  from  the  fundus. 


Fig.  316 


Line  of  suture  approximating  the  surface  of  the  wedge  removed  from  the  fundus. 


The  following  solutions  are  applied  to  the  cervical  endometrium  by 
means  of  swabs:  nitrate  of  silver,  25  per  cent.;  protargol,  5  per  cent.; 
argyrol,  40  per  cent.;  formalin,  full  strength;  zinc  chloride,  5  per  cent. 
In  making  these  applications  the  cervix  is  exposed  through  a  bivalve 
speculum  and  a  pledget  of  cotton  is  placed  back  of  the  cervix  to  protect 
the  vaginal  walls.     A  satisfactory  method  of  treatment   is  to  inject 


PLATE    XXII 
m 


b       ^fM 


Fig.3. 


h. 


oa 


OU  Qjy 

Figure  l',  a.  Salpingitis  Cutarrhalis  Hemorrhagica,  Cross-section,  m.  Muscle  of  the  tube. 
71.  Mucosa  of  the  tube.  /.  Lumen  of  the  tube.  Picrocarmine  stain.  (Hartnack,  Oc.  2;  Objec- 
tive 4.)  &.  Leucocytes  containing  blood  pigment  witli  normal  red  blood-corpuscles  from  the 
tubal  mucosa.      (Harnack,  Oc.  2;    Objective  7.) 

Figure  2.  Salpingitis  Purulenta  Acuta  Dextra.  ou.  Uterine  opening  of  tube.  oa.  Abdominal 
end  of  tube.     ov.    Right  ovary.     /.    Purulofibrinous  deposit.     Posterior  view,  natural  size. 

Figure  3.  Salpingitis  Purulenta  Chronica  Dextra.  ou.  Uterine  end  of  tube.  oa.  Region  of 
abdominal  end  of  tube.      ov.    Ovary  with  strongly  adherent  tube.      Posterior  view,  natural  size. 

1  August  INIartin,  Krankheilen  der  Eileiter. 


TREATMENT  OF  INFLAMMATIONS  OF  THE   UTERUS       443 

a  5  per  cent,  solution  of  zinc  chloride  into  the  cervical  canal  by  means 
of  a  small  syringe,  using  a  long  curved  nozzle.  (See  Fig.  603.)  Care 
must  be  taken  not  to  overdo  this  treatment  for  fear  of  creating  stenosis 
of  the  cervix.  The  author  does  not  advise  the  use  of  the  solution 
oftener  than  once  in  ten  days,  and  not  more  than  three  or  four  times. 
Vaginal  douches  of  bichloride,  1  to  2000,  or  formalin,  1  to  2000  to 
1  to  4000,  should  be  given  twice  daily. 

Fig.  317 


Excision  of  a  cervical  polj^p. 


Craig  advises  the  dilatation  of  the  cervical  canal  followed  by  curet- 
tage of  the  cervical  mucosa.  This  process  may  have  to  be  repeated 
several  times  at  intervals  of  two  weeks.  Following  each  curettage  the 
author  recommends  the  application  of  formalin  in  full  strength. 

In  cases  which  resist  all  treatment  the  cervix  should  be  amputated. 
(See  Amputation  of  Cervix.) 

All  polyps  of  the  cervix  demand  removal,  and  there  should  always  be 
a  microscopic  examination  of  the  excised  tissues  in  view  of  finding  a 
possible  malignant  growth. 


444  INFLAMMATIOXS  OF  THE   UTERUS 

Treatment  of  Erosions  of  the  Cervix. — In  the  management  of  ero- 
sions of  the  ce^^'ix  it  should  be  borne  in  mind  that  by  the  removal  of 
the  cause,  which  in  the  majority  of  cases  is  resident  in  the  uterus,  the 
lesion. will  ordinarily  heal  spontaneously.  That  is  to  say,  if  the  leucor- 
rheal  discharge  ceases,  the  erosions  will  usually  heal  without  direct 
interference. 

The  treatments  commonly  given  in  the  office  for  the  cure  of  erosions 
are  often  more  harmful  than  beneficial;  they  are  directed  to  a  condi- 
tion which  is  of  secondary  importance  as  compared  with  endometritis 
and  other  lesions  resident  in  the  uterus  and  adnexse  which  give  rise 
to  the  discharges,  and  thereby  to  the  erosion. 

Untold  harm  is  done  the  patient  by  calling  her  attention  to  the 
existence  of  the  lesion  and  by  magnifying  its  clinical  import.  It  is 
ill  advised  to  even  hint  to  these  patients  that  the  erosion  may  develop 
into  a  cancer. 

Simple  erosions  demand  no  further  treatment  than  the  removal  of 
the  cause  of  the  leucorrheal  discharges,  for  with  the  removal  of  the 
discharges,  spontaneous  healing  will  follow. 

Distended  follicles  (cysts  of  Xabothii)  should  be  opened  with  a 
knife  and  the  cavity  swabbed  with  pure  carbolic  acid. 

^Vhen  the  erosion  resists  treatment,  as  outlined  above,  the  eroded 
area  should  be  painted  with  pure  carbolic  acid  once  or  twice  a  week, 
and  following  this  the  surface  should  be  painted  with  tincture  of  iodine. 
This  will  eftectually  destroy  the  surface  epithelium  and  allow  the 
healing  of  the  erosion  by  squamous  epithelium.  Several  weeks  may  be 
required  in  the  process.  The  applications  should  not  be  made  oftener 
than  once  a  week. 

Papillary  and  follicular  erosions  demand  more  serious  consideration, 
and  particularly  so  if  the  tissues  of  the  cervix  are  deeply  infected  and 
if  deep  lacerations  exist. 

When  the  vaginal  portion  of  the  cervix  has  undergone  changes  that 
are  permanent,  nothing  short  of  excision  of  the  affected  tissues  will 
afford  relief.  Schroeder's  wedge-shaped  amputation  of  the  cervix  is  the 
operation  of  choice  in  these  cases.  It  should  always  be  preceded  by 
curettage  and  the  swabbing  of  the  uterus  with  pure  formalin,  unless  a 
purulent  discharge  exists,  when  the  curet  should  be  substituted  by  the 
application  of  formalin  or  zinc  chloride  to  the  infected  endometrium. 
(For  the  technic  of  Schroeder's  operation  see  Amputation  of  Cervix.) 

It  should  be  remembered  that  above  these  erosions  is  usually  found 
a  congested  and  infected  uterus,  if  not  a  more  extended  involvement 
of  structures  lying  beyond  the  uterus.  It  is  therefore  imperative  to 
carry  on  a  course  of  depleting  treatment  for  a  variable  time  after  the 
healing  of  the  erosion.     (See  Chronic  Metritis,  page  438.) 

By  depleting  treatment,  reference  is  made  particularly  to  long- 
continued  hot  douches  and  glycerin  and  ichthyol  tampons.  The  douches 
are  given  twice  daily  and  the  tampons  three  times  a  week  until  all 
evidence  of  pelvic  congestion  is  relieved.  During  this  course  of  treat- 
ment sexual   intercourse   and  all  strenuous  exercises  are  interdicted. 


CHAPTER    XX 

CIRCULATORY  DISTURBANCES,  INFLAMMATIONS,  AND 

INFECTIOUS  GRANULOMATA  OF  FALLOPIAN 

TUBES  AND  OVARIES 


cleculatory  disturbances  in  the 
Fallopian  Tube 
Causes 

Anatomical  Diagnosis 
Clinical  Diagnosis 
Inflammations       and       Infectious 
Granulomata  of  the  Fallo- 
pian Tube 
General  Considerations 
Classification  of  Salpingitis 
Catarrhal 
Purulent 
Tuberculous 
Syphilis  of  the  Fallopian  Tube 
Actinomycosis    of    the    Fallopian 

Tube 
Parasites  of  the  Fallopian  Tube 


Treatment  of  Inflammatory  Dis- 
eases of  the  Tubes 
Non-operative  Treatment 
Conservative  Operations 
Radical  Surgical  Treatment 
Operative  Treatment 
Circulatory  Disturbances  in  the 
Ovary 
Etiology 

Anatomical  Diagnosis 
Clinical  Diagnosis 
Inflammation  of  the  Ovary  (Oopho- 
ritis, Ovaritis) 
Acute  Ovaritis 
Chronic  Ovaritis 

Cystic  Degeneration  of  the  Ova- 
ries 
Abscess  of  the  ovary 


CIRCULATORY  DISTURBANCES  IN  THE  FALLOPIAN  TUBES 


Causes. — Whatever  interferes  with  the  general  or  local  circulation 
in  the  pelvis  may  cause  congestion  of  the  Fallopian  tubes.  Thus  dis- 
eases of  the  heart,  lungs,  liver,  and  kidney;  abdominal  tumors,  ascites, 
chronic  constipation,  and  tight-lacing  are  among  the  causes  of  tubal 
congestion- 

Infectious  diseases,  dyscrasise  of  the  blood,  burns,  toxemias,  and 
menstrual  congestion  are  additional  general  causes.  A  displaced  tube, 
one  that  is  twisted,  constricted,  or  compressed,  may  cause  congestion 
and  possibly  hemorrhages  into  the  lumen  of  the  tube. 

Anatomical  Diagnosis. — A  congested  tube  is  slightly  swollen,  dark 
red  in  color,  and  offers  unusual  resistance  to  pressure.  Hemorrhages 
may  be  seen  in  the  mucosa  and  in  the  lumen.  Necrosis  of  the  tube 
may  result  from  interference  with  the  blood  supply.  Martin  describes 
a  case  of  necrosis  of  the  tubes  as  a  result  of  mitral  insufficiency. 

When  the  ends  of  the  tubes  are  closed  and  blood  is  extravasated 
into  the  lumen  in  sufficient  quantity  the  tube  will  be  distended  into 
what  is  known  as  a  hematosalpinx.  For  further  description  of  hemato- 
salpinx see  page  458. 


446  FALLOPIAX   TUBES  AXD  OVARIES 

The  microscope  shows  the  vessels  to  be  deeply  engorged  with  blood 
extravasated  into  the  tube  wall  and  lumen. 

Clinical  Diagnosis. — A  large  proportion  of  cases  may  not  be  recog- 
nized, partly  because  of  the  frequency  with  which  the  lesion  exists  in 
the  absence  of  all  clinical  manifestations  and  partly  because  of  asso- 
ciated lesions.  The  menstrual  periods  may  be  painful,  and  the  functions 
of  the  bowel  and  bladder  are  performed  with  more  or  less  discomfort. 
Tenderness  on  pressure  over  the  affected  tube  is  the  one  constant 
sign.  The  diagnosis  cannot  be  made  with  certainty  without  an 
exploratory  incision.  The  existence  of  a  possible  cause,  together  wdth 
the  finding  of  a  tube  that  is  somewhat  tender  to  pressure  and  slightly 
enlarged,  will  lead  to  a  probable  diagnosis.  It  is  impossible  to  differen- 
tiate clinically  a  congested  tube  from  a  catarrhal  salpingitis;  the  former 
is  the  forerunner  and  accompaniment  of  the  latter. 

Diagnosis. — The  diagnosis  of  hematosalpinx  will  be  referred  to  on 
page  450. 

Treatment. — See  page  467. 


INFLAMMATIONS  AND  INFECTIOUS  GRANULOMATA  OF  THE 
FALLOPIAN  TUBES 

General  Considerations. — Of  all  lesions  of  the  Fallopian  tubes  the 
inflammatory  are  most  commonly  observed.  Of  the  various  exciting 
causes  of  salpingitis,  Noeggerath  and  Wertheim  place  the  gonococcus 
at  the  head  of  the  list  of  microorganisms.  In  302  cases  of  inflammatory 
lesions  in  the  tubes  there  were  S3  in  which  living  microorganisms  were 
found,  and  of  this  number  56  were  gonococci,  11  streptococci,  6  staphy- 
lococci, 1  pneumococcus,  while  122  were  sterile.  The  fact  that  such 
a  large  percentage  were  sterile  adds  to  the  difficulty  in  determining  the 
essential  microbic  cause.  Xeisser,  in  143  cases,  found  the  gonococcus 
in  80  after  a  latent  period  of  from  two  months  to  eight  years.  He 
emphasizes  the  necessity  of  repeated  examinations  and  faultless  technic. 
]Mixed  infections  are  of  common  occurrence. 

The  path  of  invasion  is  usually  by  way  of  the  uterus,  less  frequently 
by  the  abdominal  route  from  the  ovary,  bowel,  and  peritoneum,  and 
rarely  by  way  of  the  lymph-  and  blood-streams. 

The  manipulation  of  an  infected  uterus,  in  the  process  of  an  exami- 
nation or  operation,  is  doubtless  often  responsible  for  extension  of  the 
infection  from  the  uterus  to  the  tubes. 

-  There  are  no  pathognomonic  symptoms  of  salpingitis  and  none  that 
is  invariably  present.  Associated  inflammatory  lesions  in  the  genital 
tract  are  nearly  always  found,  and  hence  it  is  that  the  s^Tnptoms  of  the 
one  are  so  intimately  associated  with  those  of  the  other;  therefore  it  is 
difficult  to  obtain  a  clinical  picture  of  salpingitis. 

Again,  the  innervation  of  the  tubes,  ovaries,  and  uterus  is  so  inti- 
mately connected  as  to  bring  these  organs  into  close  sympathy  one 
with  the  other. 


PLATE    XXIII 


Bulb  of  the  Ovary  and  its  Venous  Communications.     (Savage. 

O,  ovary;    T,  Fallopian  tube;    U ,  uterus;   1,  uterine  vein  an<i  plexus;   2,  subovarian 
venus  plexus;   3,  commencement  of  ovarian  \ein. 


Fig.    2 


Mesosalpinx    Laid  Open,  showing  the  Parovariuni  or 
Organ  of  RosenmiLiller.     (Savage.) 

T,  Fallopian  tube;  F,  fimbriated  extremity  of  same;  O,  ovary;   1    remnant  of  Wolffian  duct; 
2,  2,  remnants  of  the  cecal  tubes  of  the  Wolffian  bodies;  3,  ovarian  ligament. 


CLASSIFICATIOX  OF  SALPIXGITIS  447 

Pain  is  the  most  constant  symptom,  and  yet  advanced  cases  of 
salpingitis  exist  in  the  absence  of  pain.  Temperature  has  but  Kttle 
diagnostic  value.  Sterility  does  not  necessarily  follow  as  the  result 
of  double  salpingitis,  though  it  is  the  rule.  An  occluded  lumen  may 
eventually  become  patent  and  permit  the  passage  of  the  ovum. 

The  history  of  infection  and  the  clinical  course  of  the  disease  cannot, 
in  themselves,  suffice  for  a  diagnosis,  but  must  be  supported  by  direct 
palpation  of  the  diseased  tubes. 


CLASSIFICATION  OF  SALPINGITIS 

I.  Catarehiyl  Salpingitis. 

1.  Acute  catarrhal  salpingitis  (endosalpingitis). 

2.  Chronic  catarrhal  salpingitis. 

a.  Salpingitis  isthmica  nodosa. 
End-stages : 

a.  Hydrosalpinx. 
h.  Hematosalpinx. 
11.  Purulent  Salpingitis. 

1.  Acute  suppm-ative  salpingitis. 

a.  Septic. 

1.  Puerperal. 

2.  Non-puerperal. 

b.  Gonorrheal. 

2.  Chronic  suppurative  salpingitis. 
End-stage :  Pyosalpinx. 

III.  Tuberculous  Salpingitis. 

I.  Catarrhal  Salpingitis.— Etiology.— The  statistics  of  Martin  illus- 
trate the  frequency  of  the  lesion.  In  1402  operations  on  the  tubes 
415  (29.5  per  cent.)  were  for  catarrhal  salpingitis. 

As  a  rule,  the  lesion  is  secondary  to  inflammatory  diseases  of  the 
uterus,  which  extend  by  direct  continuity  of  tissue.  Primary  catarrhal 
salpingitis,  in  the  absence  of  an  inflammatory  lesion  elsewhere  in  the 
pelvis,  is  an  unusual  occurrence. 

The  causes  of  catarrhal  salpingitis  are  thermic,  mechanical,  chemical, 
and  microbic. 

1.  Thermic  influences  resulting  in  salpingitis  can  scarcely  act  directly 
because  of  the  deep-seated  location  of  the  tube.  :\Ienstrual  congestion 
from  chilling  of  the  body  may  be  placed  in  this  category. 

2.  Mechanical  causes  have  a  greater  significance.  Such,  for  example, 
are  digital  and  instrumental  manipulations,  sexual  excesses,  massage, 
and  overstrain  in  lifting  and  walking. 

3.  Chemical  irritants  in  the  form  of  antiseptics  injected  into  the 
uterus  may  pass  into  the  tubes  and  set  up  a  salpingitis. 

4.  Pathogenic  microorganisms  are  by  far  the  most  essential  and 
prevailing  factors  in  the  causation  of  catarrhal  salpingitis. 

It  is  not  always  possible  to  distinguish  between  the  above-named 


448  •        FALLOPIAN  TUBES  AND  OVARIES 

causes  in  a  given  case  of  catarrhal  salpingitis.  Two  or  more  factors 
may  operate  to  bring  about  the  same  result.  Of  the  general  diseases 
complicated  by  catarrhal  salpingitis,  mention  may  be  made  of  the 
infectious  and  contagious  diseases,  notably  tuberculosis,  and  malaria. 

Anatomical  Diagnosis. — In  acute  catarrhal  salpingitis  the  tube  is  of  a 
livid  or  dark  red  color,  slightly  thickened  and  convoluted.  Its  consist- 
ency is  increased  to  a  limited  degree,  and  the  fimbrise  are  red,  swollen, 
and  retracted  to  a  variable  degree  preparatory  to  a  possible  closure  of 
the  abdominal  end  of  the  tube.  On  cross-section  of  the  tube  the  mucosa 
rolls  out  and  is  congested  and  thickened.  In  the  lumen  of  the  tube  is 
a  variable  amount  of  serous  fluid.     No  adhesions  surround  the  tube. 

The  microscopic  diagnosis  is  based  upon  marked  congestion  and 
infiltration  with  small  round  cells  in  the  mucosa  and  to  a  less  degree 
in  the  musculature.  Here  and  there  are  hemorrhagic  extravasations 
into  the  connective-tissue  spaces.  The  epithelial  lining  of  the  tube 
lumen  may  be  normal,   but  in  long-standing  lesions  the   cells  may 

Fig.   318 


Chronic  catarrhal  salpingitis.  The  tube  is  about  double  the  normal  size.  Its  course  is  irregular, 
and  the  serous  covering  is  congested.  The  fimbrise  are  swollen,  but  do  not  occlude  the  abdominal 
opening  of  the  tube. 

degenerate  and  become  desquamated.  The  secretion  found  in  the 
lumen  of  the  tube  is  in  great  part  lymph  mixed  with  blood  cells  and 
degenerated  epithelium.  From  the  acute  stage  the  tube  may  early 
resolve  into  a  normal  condition,  suppuration  may  follow,  or,  as  is  not 
infrequently  the  case,  the  acute  stage  may  pass  into  the  chronic. 

In  chronic  catarrhal  salpingitis  the  tube  is  enlarged  in  all  diameters  and 
is  correspondingly  convoluted.  The  tube  is  of  firmer  consistency  than 
in  the  acute  stage.  The  mucosa  and  muscularis  are  thickened  through 
congestion  of  the  bloodvessels  and  hyperplasia  of  the  connective  tissue. 
The  epithelium  lining  the  tube  lumen  may  be  destroyed.  Following 
this  the  lumen  may  be  obliterated  by  adherence  of  the  denuded  mucous 
folds.  Adjacent  folds  of  mucous  membrane  may  adhere  by  their  free 
margins  and  lock  in  spaces  which  are  filled  with  a  serous  secretion  and 
lined  with  columnar  epithelium,  thereby  closely  simulating  retention 
cysts  formed  from  glands.  The  mucous  folds  become  club-shaped  from 
congestion  and  an  inflammatory  exudate.  The  peritoneal  covering  of 
the  tube  may  be  involved,  and  adhesions  may  surround  the  tube  and 


CLASSIFICATION  OF  SALPINGITIS 


449 


close  up  the   fimbriated  end,   and  this  leads  to  the   formation  of  a 
hydrosalpinx. 

Salpingitis  isthmica  nodosa  is  regarded  by  Chiari  and  Schauta  as 
a  circumscribed  interstitial  salpingitis,  located  in  the  isthmus  of  the 
tube  and  forming  a  nodular  enlargement,  varying  in  size  from  that 
of  a  split  pea  to  a  bean.  Gebhard  regards  these  growths  as  benign 
adenomata. 

Fig.   319 


Hydrosalpinx.  The  tube  is  distended  with  serum  into  an  irregular  retort-shaped  mass  the  size  of 
a  fetal  head.  The  wall  of  the  cyst  is  thin  and  transparent.  The  uterine  end  of  the  tube  is  not  distended. 
A  normal  ovary  lies  adherent  to  the  distended  tube.     (Specimen  removed  by  Dr.  J.  Clarence  Webster.) 

Hydrosalpinx  (sactosalpinx  serosa)  is  the  end  stage  of  catarrhal  sal- 
pingitis. The  ends  of  the  tube  become  closed  and  the  pent-up  secretion 
distends  the  tube  into  a  serous  sac.  Because  the  thin,  distended, 
fimbriated  end  of  the  tube  offers  little  resistance  to  the  accumulated 
fluid,  the  tube  distends  at  the  outer  end  to  a  far  greater  extent  than 
at  the  uterine  end,  where  the  muscular  wall  is  more  resistant  and  the 
lumen  of  the  tube  smaller.  It  is  unusual  for  the  tube  to  distend  through- 
out its  entire  length.  It  may  enlarge  to  the  size  of  a  child's  head.  The 
larger  the  tube  the  thinner  and  more  transparent  is  the  wall. 

Adhesions  to  the  tube  are  not  ordinarily  present,  and  when  present 
are  seldom  firm,  hence  hydrosalpinx  is  more  or  less  movable.     The 
fimbriated  end  is  shaped  like  a  club  or  retort.    Radiating  lines  mark 
the  adhesions  of  the  fimbriae. 
29 


450  FALLOPIAN  TUBES  AND  OVARIES 

In  the  early  stage  there  is  the  gross  and  microscopic  appearance 
of  catarrhal  salpingitis.  As  the  tube  distends  the  walls  become  thinner 
and  more  transparent;  the  mucosa  thins  and  the  musculature  is  stretched 
and  atrophied,  presenting  longitudinal  bands  of  muscle  fibers  running 
the  entire  length  of  the  tube  and  terminating  at  the  fimbriated  end 
in  a  rosette  figure. 

The  epithelium  of  the  mucosa  is  compressed  and  may  be  wholly 
lost.  The  contents  of  the  tube  is  a  clear,  serous  fluid  with  a  specific 
gravity  of  1.005  to  1.010,  and  an  alkaline  or  neutral  reaction.  Some- 
times the  fluid  is  of  a  greenish  tint,  due  to  the  presence  of  cholesterin. 
Desquamated  epithelium,  leucocytes,  and  occasionally  a  few  red  blood 
cells  are  found  in  the  fluid  contents  of  the  tube. 

When  the  uterine  end  of  the  tube  is  not  permanently  and  completely 
closed,  the  contents  may  be  periodically  discharged  into  the  uterus 
(hydrops  tubse  profluens).  As  expressed  by  Sutton,  the  blockade  at 
the  uterine  end  has  been  raised. 

The  contents  of  the  tube  may  be  absorbed,  but  it  is  unusual  for 
the  fimbriated  end  to  reopen. 

A  pyosalpinx  may  develop  from  a  hydrosalpinx  by  secondary  infection 
with  pyogenic  organisms  conveyed  through  the  uterus  or  bowels. 
Torsion  of  a  hydrosalpinx  is  a  possible  event  leading  to  the  formation 
of  a  hematosalpinx. 

Sutton  gives  the  following  reasons  for  believing  that  a  pyosalpinx 
often  resolves  into  a  hydrosalpinx: 

1.  Hydrosalpinx  is  not  found  in  acute  cases. 

2.  In  many  chronic  cases  hydrosalpinx  is  found  on  one  side  of  the 
uterus  and  pyosalpinx  on  the  other. 

3.  The  ampulla  of  a  tube  will  sometimes  be  dilated  into  a  hydro- 
salpinx, while  the  isthmus  contains  pus. 

4.  The  fluid  contents  in  a  hydrosalpinx  will  sometimes.be  colorless, 
but  the  recesses  of  the  tube  contain  caseous  material  and  cholestrin. 

5.  The  dilated  tube  in  the  hydrosalpinx  may,  as  in  pyosalpinx, 
communicate  with  a  large  ovarian  follicle  to  form  a  tubo-ovarian  cyst. 

Tvbo-ovarian  Cyst. — Here  the  ovary  is  distended  into  a  cyst  which 
communicates  with  a  hydrosalpinx  through  an  adventitious  opening. 
A  congenital  tuboovarian  cyst  has  not  as  yet  been  described.  As  a 
rule,  the  hydrosalpinx  and  ovarian  cyst  develop  independently.  Later, 
the  two  structures  unite  by  adhesions,  the  partition  wall  atrophies  and 
gives  way,  and  there  is  established  a  communication  between  the 
two.  Rokitansky  described  a  corpus  luteum  cyst  communicating  with 
a  hydrosalpinx. 

The  fimbriae  of  the  tube  may  be  found  free  in  the  ovarian  cyst  or 
adherent  to  the  inner  surface  of  the  cyst  wall. 

Hematosalpinx. — From  the  macroscopic  appearance  it  is  not  always 
possible  to  distinguish  an  inflammatory  hematosalpinx  from  one  due 
to  ectopic  pregnancy  or  to  other  non-inflammatory  causes.  The  wall 
of  the  tube  is  possibly  thicker  from  round-cell  infiltration  and  hyper- 
plasia, and  inflammatory  adhesions  may  form  about  the  tube.     In 


CLASSIFICATION  OF  SALPINGITIS 


451 


addition  there  are  usually  found  evidences  of  infection  in  the  uterus. 
A  study  of  specimens  of  hematosalpinx  will,  in  a  large  percentage 
of  cases,  lead  to  the  discovery  of  an  embryo,  an  apoplectic  ovum,  or 
chorionic  villi.  It  is  the  uniform  testimony  of  observers  that  nearly 
allfcases  of  hematosalpinx  are  due  to  ectopic  gestation. 


Fig.  320 


Tuboovarian  cyst. 

The  term  hematosalpinx  should  be  confined  exclusively  to  Fallopian 
tubes  dilated  with  blood  and  in  which  there  is  no  evidence  of  preg- 
nancy. A  dilated  tube  containing  chocolate-colored  fluid  is  not  to 
be  classed  as  hematosalpinx. 

The  gross  and  microscopic  appearances  of  hematosalpinx  do  not 
differ  greatly  from  those  of  hydrosalpinx,  with  the  exception  of  the 
contents  and.  the  dark  red  color  which  is  imparted  by  the  contents. 
Fluctuation  may  riot  be  so  distinct  in  hematosalpinx. 

Clinical  Diagnosis. — 1.  Acute  Catarrhal  Salyingitis. — The  clinical  pic- 
ture is  usually  that  of  uterine  catarrh  or  of  acute  pelvic  inflammation. 
The  tubes  alone  are  seldom  involved,  hence  it  is  difficult  to  clearly 
define  the  clinical  signs  of  catarrhal  salpingitis.  There  is  a  feeling  of 
weight  and  discomfort  in  the  pelvis,  often  amounting  to  acute  pain, 
which  is  located  in  one  or  both  sides.  Painful  urination  and  defecation 
are  sometimes  complained  of. 


452 


FALLOPIAX   TUBES   AND  OVARIES 


The  initial  chill,  followed  by  a  rise  of  temperature,  which  is  accom- 
panied by  flashes  of  heat  and  cold,  may  be  due  to  the  salpingitis,  but 
is  more  often  the  result  of  extensive  lesions  in  other  parts  of  the  pelvis. 

It  is  possible  for  catarrhal  salpingitis  to  exist  without  the  knowledge 
of  the  patient. 

The  diagnosis  must,  therefore,  rest  largely  upon  the  local  findings, 
for  in  the  absence  of  a  physical  examination  no  positive  diagnosis  can 
be  made.  Because  of  pain  and  tenderness  the  tubes  cannot  be  palpated 
without  an  anesthetic.  The  tube  as  outlined  in  a  bimanual  examination 
is  about  the  size  of  the  little  finger;  it  is  movable,  slightly  more 
resistant  to  pressure  than  the  normal  tube,  and  at  the  fimbriated  end 
the  sensation  imparted  is  that  of  a  soft,  ill-defined  mass. 

2.  Chronic  Catarrhal  Salpingitis. — Chronic  catarrhal  salpingitis  may 
arise  in  an  insidious  manner,  or  may  begin  as  an  acute  infection,  with 
all  the  symptoms  and  signs  above  referred  to.  In  the  chronic  stage 
there  is  no  temperature  and  no  increase  in  the  pulse-rate.  The 
patient  is  often  ner\-ous,  and  sufters  from  pain,  particularly  during 
the  menstrual  periods.  Sexual  intercourse  is  painful,  and  a  leucorrheal 
discharge  is  a  common  accompaniment. 


Large  hematosalpinx;  semidiagrammatic.     (Thomas  and  Munde.) 


In  the  form  described  by  Chiari  and  Schauta,  known  as  salpingitis 
isthmica  nodosa,  the  pain  during  menstruation  is  colicky  and  cramping. 
The  tenderness  on  palpation  is  not  so  great  as  in  the  acute  stage.  The 
tube  is  outlined  as  irregular,  convoluted,  and  of  the  size  of  the  thumb 
or  index  finger.  In  consistency  the  tube  is  much  firmer  than  normal, 
and  in  manipulating  the  tube  the  range  of  motion  is  observed  to  be 
restricted,  in  part  from  loss  of  flexibility,  and  in  part  from  the  presence 
of  adhesions  about  the  tube.  The  position  of  the  tubes  is  seldom 
normal.  ]\Iore  often  they  are  found  at  the  side  of  or  behind  the  uterus. 
The  uterus  may  be  drawn  to  the  aftected  side  and  restricted  in  its 
range   of  motion. 


CLASSIFICATION  OF  SALPINGITIS 


453 


111  salpingitis  isthmica  nodosa  the  nodular  swellings  near  the  horn 
of  the  uterus  are  sometimes  recognized  in  a  bimanual  examination. 
Few  cases  have  been  diagnosticated  clinically. 

Hydrosalpinx  and  hematosalpinx  are  recognized  clinically  by  the 
pressure  they  make  upon  the  surrounding  structures  and  by  direct 
palpation.  The  patient  may  be  wholly  unaware  of  the  existence  of 
the .  lesion. 

In  a  conjoined  examination,  preferably  under  anesthesia,  the  dis- 
tended tube  is  outlined  as  a  retort-shaped  mass,  tense,  elastic,  and  often 
fluctuating.  If  no  adhesions  surround  the  tube  there  should  be  a  free 
range  of  motion.  The  small  and  firm  uterine  end,  together  with  the 
outer,  rounded,  elastic,  and  fluctuating  portion,  give  the  impression  of 
an  ovarian  cyst.  The  ovary  can  rarely  be  recognized  apart  from  the 
distended  tube.  There  is  no  way  of  detecting  a  hydrosalpinx  from  a 
hematosalpinx  except  by  aspirating  or  by  an  exploratory  incision. 

Tuboovarian  cysts  are  only  recognized  after  the  cyst  is  removed. 

Fig.  322 


Right  tuboovarian  abscess  and  left  pyosalpinx.  The  right  tube  and  ovary  are  distended  with  pus, 
as  is  also  the  left  tube.  Adhesions  bind  the  right  tube  and  ovary  together  and  the  right  tube  to  the 
posterior  surface  of  the  uterus,  rectum,  and  wall  of  the  pelvis. 


II.  Purulent  Salpingitis. — Etiology. — The  causes  are  essentially  those 
of  catarrhal  salpingitis.  As  previously  stated,  catarrhal  salpingitis 
may  be  followed  by  suppuration.  On  one  side  there  may  be  a  catarrhal 
salpingitis;  on  the  other  side  a  purulent  salpingitis;  the  two  apparently 
distinct  and  separate  lesions  may  be  dependent  upon  the  same  cause. 

Following  are  the  statistics  from  the  clinic  of  A.  Martin:  In  2098 
cases  of  purulent  salpingitis,  279  were  caused  by  gonorrhea,  374  by 
puerperal  septic  infection,  19  by  tuberculosis,  13  by  syphilis.  Of  this 
number  1282  were  preceded  by  catarrhal  salpingitis.  From  the  statistics 
of  Martin,  Schauta,  Frommel,  Charrier,  Wertheim,  and  Prochowick 
376  cases  are  collected,  and  of  this  number  76  showed  a  pure  culture 


454  FALLOPIAN  TUBES  AND  OVARIES 

of  the  goiiococcus,  10  a  mixed  gonococcus  infection,  15  a  staphylococcus 
and  streptococcus,  7  a  pneumococcus,  and  3  a  bacterium  coh  infection. 
In  15  there  was  doubtful  identity  and  in  215  the  tubes  were  sterile. 

In  puerperal  septic  infection  the  essential  causes  are,  in  the  order 
of  frequency,  staphylococcus  pyogenes  aureus  and  albus,  and  strep- 
tococcus pyogenes.  The  gonococcus,  the  tubercle,  and  colon  bacilli 
are  occasional  factors. 

The  infection  commonly  travels  by  direct  continuity  of  tissue, 
passing  directly  from  the  endometrium  to  the  tube.  Occasionally 
the  infection  is  conveyed  through  the  broad  ligaments  to  the  tube, 
or  from  the  peritoneum  to  the  tube. 

Infection  of  the  tubes  acquired  by  instrumental  and  digital  manipu- 
lations is  due  to  the  same  sort  of  bacteria  found  in  puerperal  infection. 

Gonorrheal  infection  of  the  tube  is  for  the  most  part  acquired  by 
sexual  intercourse,  but  may  be  conveyed  by  instruments  and  fingers, 
both  in  the  puerperal  and  non-puerperal  state.  The  infection  usually 
travels  by  continuity  of  tissue,  but  may  be  conveyed  by  the  lymph- 
and  blood-streams. 

Anatomical  Diagnosis. — 1.  In  acute  purulent  salpingitis  there  are  all 
the  evidences  of  an  intense  acute  inflammation.  The  tube  is  enlarged, 
possibly  to  the  size  of  the  thumb;  the  color  is  an  intense  red;  the  dis- 
tended bloodvessels  stand  out  prominently  under  the  serous  covering, 
and  the  fimbriae  are  swollen  and  retracted.  Early  in  the  process  the 
fimbriae  may  be  agglutinated,  thereby  completely  closing  the  abdominal 
end  of  the  tube.  These  adhesions  are  not  firm,  and  for  this  reason  the 
bimanual  examination  must  be  made  cautiously  for  fear  of  expressing 
the  pus  from  the  tube  into  the  abdominal  cavity.  From  the  naked-eye 
appearance  of  the  unopened  tube  it  is  impossible  to  say  whether  or 
not  there  is  pus  within  the  lumen. 

In  the  acute  stage  a  fresh  fibrinous  exudate  forms  about  the  tube, 
and  as  the  lesion  passes  into  the  chronic  stage  these  adhesions  extend 
and  become  more  firmly  organized.  The  elongation  of  the  tube  leads 
to  kinking  and  convolutions  in  its  course,  and  the  tube  may  be  com- 
pletely doubled  upon  itself.  In  the  lumen  of  the  tube  pus  is  accumulated 
in  varying  amounts. 

Under  the  microscope  the  tubal  wall  is  seen  to  be  congested,  and 
there  is  a  round-cell  and  leucocytic  invasion  of  its  entire  wall.  Pyo- 
genic microorganisms  can  be  demonstrated  tliroughout  the  wall.  The 
epithelium  of  the  mucosa  is  soon  destroyed,  and  the  folds  of  denuded 
mucous  membrane  adhere,  thereby  partially  or  completely  obliterating 
the  lumen  of  the  tube  and  locking  in  spaces  filled  with  pus.  Throughout 
the  muscularis  and  underneath  the  serous  covering  are  localized  areas 
of  suppuration.  In  the  pus  accumulated  in  the  lumen  and  wall  of  the 
tube  it  is  often  possible  to  demonstrate  the  presence  of  the  micro- 
organisms causing  the  infection.  The  older  the  infection  the  less  likely 
is  the  finding  of  bacteria.  There  may  be  superficial  necrosis  of  the 
mucosa  forming  a  pseudodiphtheritic  membrane.  Gonorrheal  infection 
is  more  likely  to  be  confined  to  the  mucous  membrane  than  are  the 


CLASSIFICATION  OF  SALPINGITIS  455 

other  forms.    ^Ye^theim  demonstrated  the  presence  of  the  gonococcus 
in  all  portions  of  the  tube. 

2.  In  chronic  purulent  salpingitis  the  tube  is  about  the  size  of  the 
thumb.  The  color  is  not  such  an  intense  red  as  in  the  acute  stage, 
and  the  adhesions  are  firmer  and  more  extensive.  The  fimbriae  are 
almost  invariably  adherent,  obliterating  the  abdominal  end  of  the  tube. 
The  convolutions  of  the  tube  are  bound  one  to  another,  and  are 
adherent  to  the  ovary,  uterus,  bowel,  bladder,  omentum,  and  abdomi- 
nal wall.  These  adhesions  permit  very  limited  excursions  of  the  tube. 
As  the  tube  enlarges  and  the  adhesions  contract  the  tube  and  ovary 
adhere  to  the  side  or  posterior  surface  of  the  uterus.  The  appendix 
vermiformis  and  tube  are  so  frequently  adherent  that  it  is  always 
advisable  to  inspect  the  appendix  when  the  abdomen  is  opened.  From 
the  tube  the  pus  may  evacuate  into  an  adherent  hollow  viscus  (blad- 
der, rectum).  Again,  the  infection  may  travel  from  the  bowel  to  an 
adherent  tube  and  cause  a  secondarv  infection  of  the  tube. 


Gonorrheal  metritis,  double  pyosalpinx,  and  ovarian  abscess.  The  uterus  is  uniformly  enlarged 
and  firm.  The  tubes  are  retort-shaped,  and  are  matted  to  the  distended  ovarj'  and  sides  of  the 
uterus. 

The  pus  within  the  tube  is  usually  yellow  or  grayish  yellow,  rarely 
greenish  or  blood-stained.  Nothing  can  be  ascertained  from  the  naked- 
eye  appearance  of  the  pus  as  to  its  virulence.  In  long-standing  cases 
the  formed  elements  of  the  pus  may  absorb,  leaving  a  serous  fluid. 

The  entire  wall  of  the  tube  is  thickened  through  congestion  and 
hyperplasia  of  the  connective  tissue.  Small  abscesses  may  be  seen 
in  the  mucosa,  the  muscularis,  and  underneath  the  serosa. 

Pyosalpinx  {Sactosalpinx  Purulenta). — ^\Mien  the  ends  of  the  tubes 
are  closed  the  pus  accumulates  within  the  lumen  and  distends  the  tube. 
The  greater  distention  is  at  the  fimbriated  end,  where  the  wall  is  thin. 
It  is  seldom  that  the  tube  is  distended  throughout  its  entire  length. 


456 


FALLOPIAX   TUBES  AND  OVARIES 


The  size  is  seldom  greater  than  a  man's  fist,  but  it  may  be  large  enough 
to  reach  aboAe  the  brim  of  the  pelvis  and  even  to  the  umbilicus.  The 
wall  of  the  tube  is  at  first  thickened,  but  when  greatly  enlarged  there 
is  an  irregular  thinning,  almost  to  the  point  of  rupture.  Rupture  of 
the  tube  may  take  place  at  its  lower  circumference  between  the  layers 
of  the  broad  ligament  or  at  any  point  in  the  wall  of  the  tube.  Adhesions 
usually  protect  the  peritoneal  cavity,  but  occasionally  direct  the  pus 
into  a  hollow  viseus  or  into  a  cyst  of  the  ovary.  Left  pyosalpinx  is 
prone  to  rupture  into  the  rectum. 

Fig.  324 


The  left  tube  is  distended  with  pus  and  is  adherent  to  the  posterior  surface  of  the  uterus. 

tube  and  ovarj-  are  normal. 


The  right 


The  pus  contained  within  the  distended  tube  is  found  in  various 
stages  of  preservation,  and  is  mixed  with  red  blood  cells,  degenerated 
epithelium,  fibrin,  and  detritus.  The  mucosa  atrophies  from  pressure, 
and  may  be  replaced  by  connective  tissue.  The  epithelium  is  almost 
wholly  destroyed.  The  muscle  and  connective-tissue  fibers  are  atrophied 
and  the  bloodvessels  are  limited  in  number. 

Clinical  Diagnosis. — 1.  Acute  purulent  salpingitis  is  generally  ushered 
in  by  marked  constitutional  disturbances.  There  may  be  an  initial 
chill;  this  is  followed  by  a  rise  of  temperature  and  pain  referred  to  the 
affected  tube.  In  nearly  every  instance  there  is  a  similar  lesion  in  the 
uterus  which  may  mask  the  more  limited  affection  of  the  tube.  Fre- 
quently the  infection  does  not  stop  in  the  tubes  but  is  carried  on  to 
the  ovaries  and  peritoneum,  giving  rise  to  additional  temperature 
and  pain  that  will  wholly  mask  the  clinical  manifestations  of  the 
affected  tube.  After  complete  resolution  in  the  uterus  and  peritoneum, 
the  infected  tube  may  fail  to  resolve,  and  remain  distended  with  pus. 
This  indisposition  on  the  part  of  the  tubes  to  resolve  as  readily  as  do 
other  parts  of  the  genital  tract  is  explained  in  part  by  the  lessened 


CLASSIFICATION  OF  SALPINGITIS  457 

power  of  absorption  in  the  tube,  but  in  greater  part  by  the  closure  of 
the  ends  of  the  tube,  thereby,  locking  in  the  pus. 

Repeated  exacerbations  are  the  rule.  These  are  brought  about  by 
sexual  excesses,  menstrual  congestion,  and  injudicious  exercises. 

We  seldom  find  gonorrheal  infection  in\'ading  the  tubes  before  the 
second  or  third  week  after  the  initial  infection  of  the  cervix.  As  a  rule, 
the  general  symptoms  are  not  so  well-marked  in  gonorrheal  infection 
as  in  other  forms  of  septic  infection. 

2.  Chronic  purulent  salpingitis  usually  begins  w^ith  an  acute  attack 
and  ends  in  a  pyosalpinx.  The  general  disturbances  are  in  nowise 
proportionate  to  the  extent  of  the  lesion.  x\ll  symptoms  may  be  absent 
in  the  presence  of  an  extensive  lesion.  INIenstrual  disorders  in  the 
form  of  menorrhagia  and  dysmenorrhea  are  fairly  constant  symptoms. 
Pain  in  the  region  of  the  tubes  and  referred  to  the  back  and  thighs, 
together  with  digestive  disorders,  are  common  complaints.  Sterility 
is  almost  sure  to  result  from  a  bilateral  involvement  of  the  tubes. 
Martin  reports  three  case^  of  bilateral  pyogenic  infection  of  the  tubes 
in  which  pregnancy  followed. 

Palpation  of  the  diseased  tubes  can  usually  be  accomplished  without 
difficulty.  When  found  impossible  to  clearly  outline  the  tubes,  an 
anesthetic  should  be  given.  The  uterus  is  first  located;  it  is  seldom 
found  in  the  median  line,  and  its  range  of  mobility  is  restricted.  The 
tubes  are  engaged  between  the  examining  fingers,  and  are  traced  outward 
from  the  horns  of  the  uterus  or  downward  and  backward,  beside  or 
behind  the  uterus.  They  are  felt  as  sensitive,  thickened  cords  varying 
in  consistency,  size,  position,  and  degree  of  mobility.  The  consistency  is 
always  firm  at  the  uterine  end  but  less  so  at  the  fimbriated  end.  The 
kinks  in  the  tube  are  felt  as  nodules  in  its  course.  Sensitiveness  to 
pressure  is  directly  proportionate  to  the  acuteness  of  the  inflammation. 
The  ovary  can  be  palpated  apart  from  the  tube  only  in  exceptional 
cases.  The  position  of  the  tube  largely  depends  upon  the  position  of 
the  uterus.  In  retroposition  the  tubes  and  ovaries  usually  lie  in  the 
pouch  of  Douglas.  W'ith  the  uterus  erect  and  forward  it  is  scarcely 
possible  for  the  tubes  to  reach  into  the  pouch  of  Douglas.  There  will 
be  no  fluctuation  unless  the  tubes  contain  a  considerable  amount  of 
pus. 

The  walls  of  a  pyosalpinx  are  thicker  and  more  resisting  to  the 
pressure  of  the  contained  fluid;  hence  the  tube  is  rarely  so  large  as  a 
hydrosalpinx  may  become.  Furthermore,  fluctuation  is  less  marked, 
and  there  is  greater  fixity  and  sensitiveness  to  pressure. 

The  character  of  a  pyosalpinx  should  be  determined  when  possible — 
that  is,  whether  due  to  gonorrhea,  puerperal  infection,  tuberculosis,  or 
non-puerperal  septic  causes. 

The  clinical  history  w^ill  often  lead  to  a  positive  diagnosis,  particularly 
in  gonorrheal  and  puerperal  cases.  Gonorrhea  is  assumed  to  be  the 
cause  w^hen  other  possible  factors  are  eliminated. 

The  presence  of  a  purulent  discharge  from  the  urethra  and  infection 
of  the  glands  of   Bartholin  will  lead  to   the   diagnosis  of   gonorrheal 


458 


FALLOPIAN  TUBES  AND  OVARIES 


salpingitis.  Absolute  certainty  in  the  diagnosis  is  only  obtained  by  the 
finding  of  the  gonococcus  of  Xeisser  in  the  secretion. 

Diagnosis  of  Sactosalpinx. — The  term  sactosalpinx  is  applied  to  a 
Fallopian  tube  distended  with  fluid,  i.  e.,  blood,  serum,  or  pus.  Under 
the  generic  term  sactosalpinx  are  placed  hematosalpinx,  hydrosalpinx, 
and  p3^osalpinx — the  end-stages  of  catarrhal  and  purulent  salpingitis. 
The  following  features  are  characteristic  of  sactosalpinx: 

The  ^position  is  at  the  side  of  or  behind  the  uterus,  extending  from 
the  horn  of  the  uterus  outward  or  downward.  Unless  greatly  distended 
the  tube  lies  below  the  normal  level,  most  often  close  to  the  side  of 
the  uterus  or  immediately  behind. 


Fig.  325 


Tenderness  over  the  right  and  left  Morris  points  suggests  the  presence  of  chronic  pelvic  inflammation 
Tenderness  over  the  right  Morris  point  and  appendix  suggests  appendicitis.  Tenderness  over  the 
appendix  and  both  Morris  points  suggests  chronic  pelvic  inflammation  and  appendicitis.  M,  right 
Morris  point;  IM,  left  Morris  point;  A,  appendix;  Sig,  sigmoid;  S,  anterior  superior  spine. 


The  consistency  is  so  variable  as  to  render  it  of  little  value  in  diagnosis. 
When  fluctuation  is  present  it  is  of  some  diagnostic  significance,  but 
is  so  often  absent  that  it  cannot  be  relied  upon. 

The  general  contour  is  significant.  We  generally  speak  of  sacto- 
salpinx as  being  of  retort-  or  sausage-shape.  The  tube  is  distorted  in 
proportion  to  the  degree  of  distention.  The  irregularity  in  the  course 
of  the  tube  can  usually  be  noted  in  a  bimanual  examination.  The 
tube,  may  be  so  snugly  twisted  upon  itself  as  to  give  to  the  examining 
finger  the  impression  of  a  round  or  oval  swelling.    So  firmly  may  the 


CLASSIFICATION  OF  SALPINGITIS  459 

tube  adhere  to  the  uterus  that  the  two  are  felt  as  a  single  mass.  The 
outline  of  the  tube  may  be  lost  in  a  surrounding  inflammatory  exudate. 

The  Diagnosis  of  the  Contents  of  a  Sactosalpinx. — Following  the 
recognition  of  a  sactosalpinx  it  is  next  important  to  determine  the 
contents  of  the  distended  tube.  This  can  only  be  done  with  certainty 
by  an  exploratory  puncture  through  the  vagina  or  by  an  exploratory 
incision.  The  danger  of  carrying  infection  into  the  tube  by  the  explor- 
ing needle  is  not  to  be  disregarded.  Fortunately  the  indications  for 
such  a  procedure  are  limited,  because  whether  blood,  pus,  or  serum  is 
present  an  operative  procedure  is  indicated. 

Differential  Diagnosis  of  a  Sactosalpinx. — Kelly  gives  the  following 
differential  diagnosis  between  gonorrheal  and  streptococcic  infection  of 
the  tube: 

Gonorrheal  Infection  Streptococcic  Infection 

1.  Slow  in  its  onset,  often  preceded  by  inflam-         1.  Onset  abrupt,  following  miscarriage,  normal 

mation  of  the  external  genitals  and  urethra.  labor,  or  topical  applications. 

2.  Pain  localized  in  one  or  both  ovarian  regions.  2.  Pain  more  general  and  severe  in  the  lower 

abdomen. 

3.  No  signs  of  general  peritonitis.  3.   Usually  signs  of  peritonitis. 

4.  Suffers  more  or  less  constantly,  but  may  have         4.  Suffers  constantly,  and  usually  has  a  septic 

no  fever.  fever. 

5.  Temperature  98.5°  to  102°  F.  (38.9°  C).  5.  Temperature  101°  to  105°  F.  (38.3°  to  40.5° 

C). 

6.  Pulse  accelerated,  but  of  good  quality.  6.  Pulse  never  feeble  and  is  more  rapid. 

7.  Attack  lasts  from  five  to  fifteen  days.  7.  Attack  seldom  lasts  less  than  a  month,  and 

may  continue  three  months  or  more. 

8.  Often  presents  the  appearance  of  good  health.         8.  Anemic  and  weak. 

9.  Gonococci  usually  found  on  cover-shp  prepa-         9.   Gonococci  not  found  in  the  secretions. 

ration  from  the  cervical,  urethral,  or  ^idvo- 
vaginal  glandular  secretions. 
10.   Historv  of  marital  gonorrhea.  10.  Husband  sound. 


Appendicitis  Tuboovarian  Disease 

1.  No  previous  local  disturbances.  1.  Genito-urinarj'     functions     previously     dis- 

turbed.     Usually  a  history   of  gonorrheal 
or  puerperal  infection. 

2.  Chill  usually  absent.  2.   Chill  may  precede  fever. 

3.  Pain  in  right  iliac  region,  sudden  onset,  acute,         3.  Gradual   onset,    pain   dull,    continuous,    and 

and  not  radiating  to  thighs.  radiating. 

4.  Fever  of  variable  degree.  4.   Fever  often  entirely  absent. 

5.  Muscular  rigidity  on  right  side  of  the  abdo-         5.   No  muscular  rigiditj'  unless  complicated  bj' 

men.  peritonitis. 

6.  Inflammatory  exudate  about  appendix  three         6.   Inflammatorj-  exudate  in  the  pelvis  felt  by 

to  five  days  after  onset  of  symptoms.  vaginal  examination  at  the  onset  of  the 

symptoms. 

7.  Vaginal    examination    is    rarely    painful    in         7.  Always  painful  in  tuboovarian  disease. 

appendicitis. 

Krussen  says  the  appendix  is  involved  in  15  per  cent,  of  cases  of 
tuboovarian  disease. 

]\Iartin  found  appendicitis  complicating  right-sided  salpingitis  13 
times  in  276  cases.  Ochsner,  in  51  cases  of  appendicitis,  found  the 
tube  and  ovary  involved  15  times.  Because  of  the  frequency'  with 
which  appendicitis  and  salpingitis  are  associated,  an  inflammatory 
lesion  in  the  right  side  of  the  pelvis  should  suggest  a  possible  involve- 
ment of  both  of  these  structures,  and  no  operation  is  complete  on  either 
of  these  structures  without  investigating  the  condition  of  the  other.  It 
is  possible  for  a  primary  appendicitis  to  extend  to  the  rectocecal  con- 
nective tissue  and  on  to  the  pelvic  connective  tissue,  giving  rise  to  a 
secondary  parametritis.     A  similar  extension  may  take  place  along 


400 


FALLOPIAX   TUBES  AXD  OVARIES 


the  peritoneum  from  the  cecum  to  the  tubes  and  o\-aries.  The  history 
of  the  onset  and  the  previous  comphnnts  are  important  considerations. 
Next  in  point  of  importance  is  the  position  of  the  swelhng.  Tume- 
factions in  and  about  the  tube  are  intimately  connected  with  the  uterus, 
and  can  be  traced  to  its  horn.  In  appendicitis  the  swelling  is  high  up 
in  the  right  iliac  space,  and  in  enlarging  it  extends  downward  into  the 


Appendix  adherent  to  fundus  of  uterus  and  right  Fallopian  tube.    An  acute  attack  of  appendicitis 

followed  pregnancy. 


pelvis  in  contrast  to  the  swellings  of  tuboovarian  diseases,  which 
extend  upward  from  the  pelvis.  In  appendicitis  it  may  be  possible 
to  palpate  the  tube  and  ovary  apart  from  the  exudate  about  the 
appendix. 

A  subserous  fibroid  may  be  simulated  by  pyosalpinx  when  the  tube 
is  round,  thick-walled,  closely  adherent  to  the  uterus,  and  surrounded 
by  a  firm,  sharply  defined  exudate. 

The  clinical  history  is  important.  In  pyosalpinx  there  is  a  history 
of  infection,  either  puerperal  or  gonorrheal,  while  in  fibroids  no  such 


CLASSIFICATION  OF  SALPINGITIS  461 

history  is  obtainable.  In  subserous  fibroids  the  tumor  is  round,  sharply 
circumscribed,  not  tender  to  pressure,  usually  freely  movable,  and 
unilateral.  In  pyosalpinx  the  tumor  is  more  elongated,  less  sharply 
defined,  tender  to  pressure,  immovable,  and  often  bilateral.  In  pyo- 
salpinx there  are  evidences  of  infection  in  the  lower  genital  tract, 
while  with  fibroids  such  is  not  the  case. 

Parametritic  exudates  are  often  associated  with  pyosalpinx,  and  their 
differentiation  may  be  impossible.  The  location  and  general  contour 
of  the  swelling  are  the  distinguishing  features.  The  onset  and  general 
clinical  manifestations  closeh'  simulate  each  other. 


Fig.  327 


Appendix  adherent  to  tube  and  ovary  in  pregnancy. 

A  pyosalpinx  is  often  bilateral,  while  a  parametritic  exudate  is  com- 
monly unilateral.  The  former  lies  on  a  higher  level  at  the  side  of  or 
behind  the  uterus,  while  the  latter  lies  low  in  the  pelvis  in  direct  contact 
with  the  vault  of  the  vagina,  running  from  the  sides  of  the  uterus 
directly  outward.  A  pyosalpinx  is  more  sharply  circumscribed  and  is 
retort-  or  sausage-shaped.     A  parametritic  exudate  is  ill-defined. 

Ovarian  and  parorarian  cysts  may  closely  resemble  a  hydrosalpinx. 
The  diagnosis  must  be  reserved  for  an  exploratory  incision.  Hydro- 
salpinx is  more  often  bilateral  and  elongated,  and  is  more  limited  in 
size. 

New-formations  of  the  tubes  are  very  rare  as  compared  with  inflam- 
matory lesions.  The  presence  of  ascites  associated  with  tubal  swellings 
speaks  in  favor  of  malignant  new-formations  of  the  tubes. 

For  the  differential  diagnosis  of  salpingitis  from  tubal  pregnancy, 
see  Chapter  IX. 


462  FALLOPIAN  TUBES  AND  OVARIES 

Twisted  Pedicle  of  a  Sactosalpinx. — It  is  possible  for  a  sactosalpinx 
to  twist  upon  its  long  axis.  Anspach^  has  contributed  an  admirable 
discussion  on  "Torsion  of  Tubal  Enlargements."  None  of  the  cases 
had  been  correctly  diagnosticated  before  opening  the  abdomen.  They 
were  mistaken  for  appendicitis,  ectopic  pregnancy,  twisted  pedicle  of 
an  ovarian  cyst,  strangulation  of  the  bowel,  and  gynatresia. 

From  one  to  four  twists  have  been  found  in  the  pedicle,  and  the 
circulatory  disturbances  may  be  sufficient  to  cause  gangrene. 

It  is  hardly  conceivable  that  the  normal  tube  can  twist  upon  its 
long  axis,  but  when  the  outer  end  of  the  tube  is  enlarged  and  not 
adherent,  conditions  are  favorable  for  twisting  at  the  pedicle  of  the 
distended  ampulla  of  the  tube.  The  exciting  and  predisposing  causes 
are  the  same  as  found  in  the  ^twisting  of  the  pedicle  of  an  ovarian  cyst. 
(See  Ovarian  Tumors.) 

Fig.   328 


Anspach's  case  of  right,  twisted  pyosalpinx.     Left,  tuberculous  pyosalpinx. 

III.  Tuberculous  Salpingitis. — Etiology. — In  this  country  our  knowl- 
edge of  tuberculosis  of  the  tubes  is  largely  contributed  to  by  Williams, 
Penrose,  and  Edebohls. 

The  following  statistics  are  from  Veit: 

Wenkel  found  tuberculosis  5  times  in  575  cases. 

Donhoff  found  tuberculosis  14  times  in  509  cases. 

Schramm  found  tuberculosis  34  times  in  3389  cases. 

Rosthorn  found  tuberculosis  2  times  in  40  cases. 

Williams  found  tuberculosis  7  times  in  91  cases. 

Martin  found  tuberculosis  17  times  in  620  cases. 

The  above  constitute  a  sum  total  of  79  in  5224  cases,  or  1  case  of 
tuberculous  salpingitis  in  66  abdominal  sections. 

Kundrat  in  140  abdominal  sections  for  the  removal  of  diseased 
uterine  appendages,  found  tuberculous  salpingitis  in  4  cases  and  tuber- 
culous endometritis  in  1  case. 

1  Amer.  Jour.  Obst.,  October.  1912. 


CLASSIFICATION  OF  SALPINGITIS  463 

Williams  is  undoubtedly  correct  in  his  statement  that  tuberculosis 
often  goes  unrecognized  in  a  catarrhal  or  suppurative  salpingitis  for 
want  of  microscopic  and  bacteriological  examinations. 

At  the  Johns  Hopkins  Hospital  in  two  years'  time  8  per  cent,  of  the 
tubes  removed  for  inflammatory  lesions  were  found  tuberculous. 

The  great  frequency  of  genital  tuberculosis,  as  a  primary  lesion  in 
the  tubes,  is  shown  in  the  statistics  of  W.  jNIeyer,  who  reports  67  cases 
of  primary  tuberculosis  of  the  genital  tract,  of  which  57  were  primary 
in  the  tubes. 

We  recognize  a  primary  and  secondary  tuberculous  salpingitis. 
Hegar,  in  his  monograph  of  1886,  speaks  of  ascending  and  descending 
infections.  The  ascending  form  may  be  primary  or  secondary.  The 
descending  is  always  secondary. 

Avenues  by  Which  the  Tubercle  Bacillus  Gains  Access  to  the  Tubes. — 
1.  By  the  blood  current  (metastatic  invasion),  as  found  in  secondary 
involvement  of  the  tubes  from  a  primary  focus  in  the  lungs,  in  the 
absence  of  a  tuberculous  lesion  in  the  omentum,  mesenteric  glands, 
peritoneum,  or  bowel. 

2.  By  continuity  of  tissue,  either  from  the  peritoneum  or  the  uterus. 
In  194  cases  of  secondary  tuberculous  salpingitis  the  peritoneum  was 
primarily  involved  110  times  (Meyer).  When  the  tube  is  adherent 
to  the  bowel  at  the  site  of  a  tuberculous  ulcer,  the  infection  may  pass 
directly  from  the  bowel  to  the  tube  without  invoh'ing  the  peritoneum. 
Such  infections  are  usually  mixed  with  the  colon  bacillus.  Emmet 
described  a  case  in  which  the  tubercle  bacillus  tra^'elled  from  the 
uterus  through  the  tube  and  attacked  the  peritoneum,  leaving  the 
tube  free. 

3.  By  way  of  the  lymph  current  tuberculosis  may  be  conveyed  from 
the  lower  genital  tract  through  the  broa.d  ligaments  without  passing 
through  the  uterus. 

The  infection  is  conveyed  to  the  genital  tract  by  the  examining 
■fingers,  instruments,  and  coitus.  Tuberculosis  may  be  conveyed  from 
the  husband  to  the  genital  organs  of  the  wife,  even  though  his  sexual 
organs  are  normal. 

The  infection  may  travel  direct  to  the  tubes  without  attacking  the 
uterus,  vagina,  or  vulva. 

As  predisposing  causes  may  be  mentioned  age,  the  puerperium,  and 
inflammatory  lesions  of  the  tubes.  Tuberculous  salpingitis  may  be 
found  at  any  period  of  life  from  infancy  to  old  age,  the  greatest  number 
occurring  from  fifteen  to  thirty  years  of  age.  The  age  limits  are  wider 
than  in  any  of  the  other  forms  of  tuberculosis.  The  puerperal  uterus, 
and  particularly  the  placental  site,  is  especially  susceptible  to  tuber- 
culous infection. 

Inflammatory  lesions  of  the  tubes  are  likely  to  have  tuberculosis 
engrafted  upon  them.  Thus  there  are  mixed  infections  of  the  tubercle 
bacillus,  with  the  gonococcus,  staphylococcus,  streptococcus,  and  colon 
bacillus. 


464  FALLOPIAN   TUBES  AND  OVARIES 

Anatomical  Diagnosis. — As  in  other  forms  of  salpingitis  there  is  an 
acute  and  chronic  stage. 

Acute  tuberculous  salpingitis  is  seldom  encountered.  The  tube 
resembles  the  catarrhal  form.  There  is  a  slight  increase  in  the  size 
of  the  tube,  together  with  marked  congestion;  the  mucosa  is  swollen, 
and  the  secretion  increased.  The  entire  wall  of  the  tube  is  infiltrated 
with  small  round  cells,  and  in  addition  to  these  changes,  which  are 
those  of  acute  catarrhal  salpingitis,  giant  cells,  tubercles,  and  tubercle 
bacilli  are  found  in  the  mucosa  and,  to  a  lesser  degree,  in  the  muscularis. 
The  lesion  is  more  pronounced  in  the  fimbriated  end.  The  secretion 
collected  in  the  lumen  may  be  serous,  bloody,  or  purulent. 

From  the  acute  stage  the  lesion  may  merge  into  a  chronic  stage, 
resembling  chronic  catarrhal  or  chronic  suppurative  salpingitis. 

Fig.  329 


Tuberculosis  of  the  uterus,  tubes,  and  ovaries.  The  surface  of  the  uterus,  tubes,  and  ovaries  is 
covered  with  miliary  tubercles  by  direct  extension  from  the  peritoneum.  The  appendages  are  matted 
and  enlarged  (tuberculous  salpingitis  and  ovaritis). 

Miliary  tubercles  may  aggregate  to  form  large  tubercles  and  nodules, 
which  in  turn  may  undergo  caseous  degeneration.  The  lumen  of  the 
tube  may  be  filled  with  caseous  material.  A  tuberculous  pyosalpinx 
may  form  after  the  closure  of  either  end  of  the  tube. 

There  is  no  way  of  distinguishing  tuberculosis  of  the  tubes  either 
in  the  acute  or  chronic  stage  from  catarrhal  or  suppurative  salpingitis, 
except  by  the  discovery  of  tubercles,  giant  cells,  or  tubercle  bacilli. 
For  this  reason  tuberculosis  in  a  tube  is  often  overlooked. 

Gray  or  yellowish-gray  tubercles,  range  in  size  from  a  miliary  tubercle 
to  a  hazel-nut;  they  may  be  seen  on  the  surface  of  the  tube  and  on  the 
peritoneum  near  b}'.  Adhesions  about  the  tube  are  usually  firm  and 
extensive. 

Williams  describes  a  chronic  fibroid  tuberculous  salpingitis  in  which 
there  is  a  marked  fibrous  hyperplasia  in  and  between  the  tubercles. 
Caseous  degeneration  is  absent.  This  is  a  very  chronic  form,  and  may 
be  regarded  as  a  healing  process. 

Calcification  of  the  tuberculous  product  in  the  tubes  is  described  by 
Kolb,  Penrose,  and  Rokitansky. 


CLASSIFICATION  OF  SALPINGITIS 


465 


Clinical  Diagnosis. — Tuberculous  salpingitis  may  be  suspected  when 
one  or  both  tubes  are  found  to  be  enlarged  and  tender  to  pressure,  and 
the  possibility  of  gonorrheal  or  puerperal  infection  can  be  excluded. 
The  presence  of  tuberculosis  elsewhere  in  the  body  or  in  the  husband, 
or  a  tuberculous  family  history,  suggest  the  cause  of  the  lesion  in  the 
tube. 

In  primary  tuberculous  salpingitis  the  symptom  of  greatest  clinical 
importance  is  prolonged  and  painful  menstruation. 


Fig.  330 


Tuberculous  tuboovarian  abscess.  The  tube  and  ovary  are  distended  with  pus,  and  together  form 
a  retort-shaped  mass  the  size  of  a  fetal  head.  The  wall  of  the  cj'st  is  thick  and  covered  with  dense 
adhesions.     (Specimen  removed  by  Dr.  J.  Clarence  Webster.) 

The  functions  of  the  bowels  and  rectum  are  frequently  disturbed. 
Abdominal  ascites  is  found  in  about  15  per  cent,  of  cases.  An  evening 
rise  of  temperature  and  increase  in  the  pulse-rate  are  significant.  As 
a  diagnostic  test,  tuberculin  may  be  administered,  but  the  test  is  not 
reliable. 

The  local  findings  do  not  difter  at  first  from  those  of  acute  and  chronic 
salpingitis.  Later  nodules  may  be  occasionally  felt  on  the  surface  of 
the  tube.  There  is  nothing  in  the  conjoined  examination  to  positively 
identify  a  tuberculous  tube. 

Hegar  lays  great  stress  upon  the  peculiar  condition  of  the  middle 
30 


466  FALLOPIAN  TUBES  AND  OVARIES 

third  of  the  tube,  which  presents  firm,  nodular  swellings.  In  the  absence 
of  peritonitis  there  are  no  findings  differing  materially  from  those  of 
salpingitis  in  general.  The  finding  of  tuberculous  peritonitis  naturally 
suggests  the  presence  of  tuberculosis  in  the  tubes.  An  exploratory 
curettage  may  disclose  tubercles  in  the  scrapings. 

In  favor  of  tuberculous  salpingitis  the  following  data  may  be  given: 

1.  The  diagnosis  of  chronic  salpingitis. 

2.  Tuberculous  lesions  elsewhere  in  the  body. 

3.  Tuberculosis  in  the  husband,  particularly  when  involving  the 
sexual  organs. 

4.  Family  history  of  tuberculosis. 

5.  Salpingitis  in  virgins  (90  per  cent,  are  said  to  be  tuberculous). 

6.  Tubercle  bacilli  in  the  leucorrheal  discharge  or  in  scrapings  from 
the  uterus. 

7.  Ascites. 

Syphilis  of  the  Fallopian  Tubes. — Literature  on  syphilis  of  the  tubes 
is  scant,  and  cases  are  of  rare  occurrence.  Nevertheless  three  authentic 
cases  are  described  by  Ballentyne  and  Williams,  Donhuff,  Bouchard, 
and  Lepine. 

Donhuff  discovered  the  usual  changes  of  catarrhal  salpingitis  in  a 
postmortem  examination  of  a  baby,  nine  days  old,  which  had  died  of 
syphilis. 

The  case  recorded  by  Ballentyne  and  Williams  was  a  seven  months' 
child.  There  were  numerous  small  gummata  scattered  throughout 
the  tube  wall  and  obliterating  the  lumen. 

Bouchard  and  Lepine  reported  a  case,  aged  forty  years.  Death 
was  from  syphilis.  There  was  a  gumma  in  each  tube  the  size  of  a 
hazel-nut,  and  the  lumina  of  the  tubes  were  occluded. 

Actinomycosis  of  the  Fallopian  Tubes. — We  know  little  of  actino- 
mycosis of  the  tubes.  Zemann,  Stewart,  Muer,  and  Granger  have 
contributed  all  that  is  now  known.  In  the  reported  cases  the  lesion 
was  both  primary  and  secondary  in  the  tubes. 

Actinomycosis  is  probably  always  a  secondary  infection  in  the  tubes. 
The  infection  takes  place  from  the  intestinal  tract,  especially  from  the 
.  appendix,  by  continuity  and  penetration. 

To  the  unaided  eye  the  lesion  presents  the  appearance  of  tuberculosis. 
In  long-standing  cases  the  abundant  supply  of  connective  tissue  formed 
in  and  about  the  appendages  may  suggest  the  possible  presence  of  a 
tumor  of  some  sort. 

Diagnosis. — The  diagnosis  can  only  be  made  by  repeated  bacterio- 
logical examinations  of  the  contained  secretions. 

When  the  affection  is  circumscribed  the  prognosis  is  favorable. 
The  treatment  consists  of  radical  removal.  Large  doses  of  the  iodide 
of  potassium  should  be  given  following  the  operation. 

Parasites  of  the  Fallopian  Tubes. — Echinococci  have  been  found  in 
the  tubes,  the  infection  being  secondary  to  that  of  the  abdominal 
viscera,  the  pelvic  bones,  and  the  paraproctal  connective  tissue.  Benoit 
reported  eighty  cases  found"  in  the  literature. 


TREATMENT  OF  INFLAMMATORY  DISEASES  OF  TUBES     467 


TREATMENT  OF  INFLAMMATORY  DISEASES  OF  THE  TUBES 

Non-operative  Methods  of  Treatment.  —  Acute  Salpingitis. — The 
treatment  of  acute  inflammations  of  the  tubes  is  essentially  that  of 
acute  pelvic  inflammation  in  general. 

Rest. — Rest  is  enjoined  in  view  of  limiting  the  infection  to  the  tube 
and  preventing  its  spread  to  neighboring  structures.  Manipulations 
of  the  tubes  in  the  early  stages  of  infection  are  dangerous,  because 
at  such  times  the  abdominal  end  of  the  tube  is  not  securely  closed  and 
the  infectious  secretions  may  be  stripped  from  the  tube  into  the  pelvic 
peritoneal  cavity.  For  this  reason  no  unnecessary  pelvic  examinations 
should  be  made  and  all  operative  measures  should  be  proscribed  unless 
drainage  per  vaginam  is  demanded  for  the  relief  of  septic  intoxication 
and  pain. 

Depletives. — Depletives  should  be  used  throughout  the  acute  stage 
and  long  after  the  acute  inflammatory  reaction  has  subsided.  For 
the  application  of  hot  douches  and  ichthyol  and  glycerin  tampons 
see  Chapter  XL  If  these  methods  are  persisted  in  the  results  will 
often  be  most  gratifying.  The  progress  of  the  infection  may  be  checked, 
exudates  within  the  lumen  of  the  tube  and  tube  wall  may  be  absorbed, 
and  if  the  inflammatory  process  has  not  gone  on  to  the  destruction  of 
cellular  elements,  and  the  building  up  of  newly  formed  connective 
tissue,  it  is  possible  that  the  tube  may  not  only  be  restored  to  func- 
tional activity,  but  to  a  perfectly  normal  anatomical  condition. 

In  addition  to  the  application  of  douches  and  tampons,  hot  hip 
packs,  hot  fomentations,  and  ice-bags  are  of  service  in  relieving  pain. 

Regulation  of  Diet  and  Boicels. — The  diet  should  be  plentiful  and 
nutritious,  and  the  bowels  kept  freely  open  with  saline  cathartics  and 
enemata.     As  a  rule,  anodynes  are  not  demanded. 

Salt  Solution. — ^When  septic  symptoms  are  manifest,  enemata  of 
normal  salt  solution  will  lessen  the  toxic  symptoms  and  add  to  the 
comfort  of  the  patient.  The  functions  of  the  bowels,  skin,  and  kidneys 
are  accelerated,  the  disturbances  of  the  stomach  due  to  toxins  are 
alleviated,  and  pain  is  lessened. 

Fraub,  of  Amsterdam,  reported  70  per  cent,  of  cures  of  salpingo- 
ovaritis  without  operative  intervention.  In  these  cases  the  uniform 
treatment  was  as  follows:  ''Complete  rest  in  bed  and  the  application 
of  an  ice-bag  as  long  as  there  was  any  fever;  the  acute  symptoms  past, 
warm  vaginal  injections  (45°  C),  vaginal  tampons,  glycerin  and  warm 
water  compresses  on  the  lower  part  of  the  abdomen.  The  duration 
of  the  treatment  varied  from  three  weeks  to  several  months ;  the  average 
duration  could  be  rated  at  about  six  weeks."  The  author  does  not 
claim  complete  cure  in  all  of  these  cases,  but  in  every  case  the  women 
were  wholly  relieved  of  their  symptoms.  In  a  limited  number  of  these 
cases,  amounting  to  433,  there  were  slight  relapses.  Fraub  holds  that 
over  one-half  the  cases  of  salpingoovaritis  necessitate  no  operative 
interference. 


468  FALLOPIAN  TUBES  AND  OVARIES 

Chronic  Salpingitis. — The  question  might  be  asked,  Should  all  tubes, 
the  seat  of  chronic  inflammation,  be  sacrificed?  This  is  the  general 
rule  of  practice,  but  in  view  of  the  fact  that  so  large  a  percentage  of 
these  cases  are  brought  to  the  state  of  functional  cure  by  the  exercise 
of  conservative  measures,  it  is  apparent  that  surgery  should  not  be 
invoked  until  non-operative  means  have  been  given  an  extended  trial. 
Surgery  cannot  replace  a  diseased  tube  by  a  normal  tube,  hence  it 
follows  that  the  removal  of  an  unoffending  lesion  of  the  tube  can  serve 
no  good  purpose. 

The  severity  of  the  symptoms  in  no  way  corresponds  to  the  extent 
of  the  lesion  in  the  tubes.  There  may  be  an  accumulation  of  pus  in 
the  tubes  in  the  absence  of  symptoms,  and  there  may  be  serious  com- 
plaint from  an  apparently  insignificant  lesion  in  the  tubes. 

As  a  general  proposition,  so  long  as  a  salpingoovaritis  lets  the  patient 
alone  we  should  let  it  alone,  so  far  as  surgery  is  concerned. 

In  the  chronic  stage  of  salpingitis  the  treatment  is  directed  toward 
relief  from  annoying  and  distressing  symptoms,  and  so  far  as  pos- 
sible, to  the  restoration  of  the  diseased  tube  to  the  normal.  When 
these  efforts,  faithfully  and  intelligently  directed,  have  failed  to  bring 
about  the  desired  results,  it  is  time  for  surgical  intervention,  but  not 
until  then. 

The  conservative  measures  applied  in  the  treatment  of  chronic 
salpingitis  are  as  follows:  Vaginal  douches  of  water  at  110°  F.,  twenty 
minutes  in  duration  and  repeated  twice  daily,  are  given  in  the  recumbent 
position.  Glycerin  (93  parts)  and  ichthyol  (7  parts)  tampons  are 
applied  daily. 

Douches  and  tampons  afford  the  most  effective  means  of  depleting 
the  congested  pelvic  tissues,  and  by  their  use,  tenderness  and  pain  are 
relieved,  inflammatory  swellings  are  reduced,  and  the  functions  of  the 
tubes  and  neighboring  organs  are  in  part  or  wholly  restored.  Under 
this  treatment,  extending  over  a  period  of  one  year,  the  author  has 
seen  a  case  of  bilateral  pyosalpinx  arrive  at  a  functional  cure,  and 
the  patient  had  a  subsequent  pregnancy  and  a  successful  delivery. 
Pelvic  massage,  properly  directed  and  persisted  in  for  the  requisite 
time,  will  bring  favorable  results  in  selected  cases,  but  in  America 
this  method  of  treatment  has  found  little  favor.  The  author  has 
personally  found  little  satisfaction  in  it.     (See  page  215.) 

Pressure  therapy  (see  page  220)  is  of  still  less  value  in  the  treatment 
of  salpingitis  because  of  the  high  location  of  the  tubes..  Freedom  from 
violent  exercise  and  careful  regulation  of  the  bowels  should  be  enjoined. 

Conservative  Operations  on  the  Tubes. — The  object  of  practising 
conservatism  in  operating  upon  the  Fallopian  tubes  is  to  maintain,  or 
provide  for,  the  function  of  childbearing.  The  one  function  possessed 
by  the  tubes  is  that  of  transmitting  the  ovum  from  the  ovary  to  the 
uterus,  and  it  is  to  restore  the  lumen  of  the  tube  throughout  its  entire 
course  that  surgery  is  invoked. 

It  was  formerly  the  custom  to  remove  the  tubes  together  with  the 
()\'ary,  but  it  has  been  repeatedly  demonstrated  that  the  ovum  may 


TREATMEXT  OF  IXFLAMMATORY  DISEASES   OF   TUBES     469 


Fig.  331 


pass  from  an  ovary  to  the  tube  of  the  opposite  side  and  there  be  fecmid- 
ated,  and  either  remain  in  the  tube  and  develop  a  tubal  pregnancy  or 
pass  through  the  tube  to  the  uterus  and  there  develop  a  uterine  preg- 
nancy. From  these  facts  we  have  learned  to  conserve  the  normal  tube 
and  even  a  small  portion  of  the  uterine  end  of  a  normal  tube  when  the 
ovary  of  the  corresponding  side  has  been  wholly  sacrificed  and  there 
is  left  all  or  a  part  of  the  ovary  of  the  opposite  side. 

The  surgical  axiom,  "save  what  can  be  saved,"  applies  to  the  surgery 
of  the  tubes  when  the  uterus  and  at  least  a  part  of  one  ovary  are  left 
intact.  AYhen  the  body  of  the  uterus  or  both  ovaries  are  removed  the 
tubes  can  serve  no  good  purpose. 

In  tubal  pregnancy  there  is  no  place  for  conservati\'e  dealing  with 
the  pregnant  tube;  it  should  be  removed  in  iota.  (For  further  discussion 
see  Chapter  IX.j 

Chronic  inflammatory  diseases  of  the  tubes  afford  possibilities  as  well 
as  uncertainties  in  conservative  operations. 

Experience  teaches  that  simple  catarrhal  inflammations  of  the  tubes, 
when  treated  tentatively,  not  infrequently  resolve  into  a  normal  state; 
and  it  has  been  observed  that  purulent 
infections  of  the  tubes  may  eventually 
cease  to  inconvenience  the  individual  and 
may  not  interfere  with  the  occurrence  of 
pregnancy.  I  have  had  one  patient  of 
bilateral  pyosalpinx  who  was  under  treat- 
ment by  douches  and  tampons  for  a  year 
and  who  subsequently  bore  a  child  with 
no  untoward  results.  ^lartin  reports  two 
such  cases. 

We  frequently  observe  cases  in  the 
acute  and  subacute  stages  of  a  pelvic  in- 
fection with  the  uterus  and  appendages 
matted  and  pus  in  and  about  the  ttibes, 
and  believe  them  to  be  hopelessly  involved; 
yet  under  tentative  treatment  they  cease  to  create  disturbance,  and 
become  so  nearly  normal  as  to  require  little  or  no  surgical  interference. 
It  therefore  behooves  one  to  be  guarded  in  his  surgery  of  the  tubes  lest 
he  remove  that  which  may  serve  a  good  purpose. 

Adhesions  about  the  tube  may  be  severed  without  sacrificing  the 
tube,  provided  the  lumen  of  the  tube  is  patent.  When  the  fimbriae  are 
matted  and  serous  secretions  have  accumulated  in  the  tube,  without 
altering  the  structure  of  the  tube  wall,  the  fimbria  may  be  teased  apart 
or  the  fimbriated  end  resected.  Whenever  there  is  a  possibility  of  a 
latent  infection  resident  in  the  tubes,  no  such  conservative  measures  are 
permissible.  Fig.  331  shows  the  completed  operation  of  salpingostomy, 
the  fimbriated  end  of  the  tube  having  been  amputated  and  the  mucosa 
stitched  to  the  serous  covering  of  the  tube.  In  this  operation  two 
essential  details  are  to  be  observed:  (Ij  The  mucosa  must  be  turned 
out   to  form   an  ectropion,   thereby  preventing    partial    or    complete 


Salpingostomy.  Mucosa  stitched 
to  the  serous  covering  of  the  tube  'vrith 
fine  plain  catgut. 


470  FALLOPIAN  TUBES  AND  OVARIES 

closure  of  the  tubal  opening,  and  (2)  the  improvised  fimbriated  end 
must  be  in  close  proximity  to  the  ovary. 

J.  Clarence  Webster  resected  the  fimbriated  end  of  a  tube,  and  at  a 
later  date  found,  upon  opening  the  abdomen,  that  fimbriae  had  reformed 
at  the  resected  end  of  the  tube. 

The  effort  has  been  made  to  conserve  part  or  all  of  a  tube  distended 
with  pus,  blood,  or  serum.  Stripping  the  tube  of  its  contained  blood 
or  pus  and  irrigating  the  tube  with  sterile  normal  salt  solution  by  means 
of  a  small  cannula  inserted  into  the  abdominal  end  of  the  tube  has  been 
advised  and  practised  by  some  operators.  Such  conservatism  is  not 
justified. 

What  Are  the  Limitations  and  Disadvantages  of  Conservatism? — The 
menopause  marks  the  end  of  usefulness  of  the  Fallopian  tubes,  because 
their  only  function,  so  far  as  known,  is  that  of  transmitting  the  ovum 
from  the  ovary  to  the  uterus. 

The  following  objections  to  the  conservative  treatment  of  diseases 
of  the  tubes  have  been  advanced: 

1.  The  return  of  disease  in  the  resected  tube. 

2.  The  uncertainty  of  restoring  the  functions  of  the  operated  tube. 

3.  Failure  to  effect  perfect  relief  from  symptoms. 

4.  Liability  of  the  disease  recurring  in  the  opposite  side. 

5.  The  danger  of  ectopic  pregnancy. 

The  above  recorded  objections  do  not  prevail  when  the  indications 
for  operative  interference  are  well  grounded,  and  when  it  is  the  desire 
of  the  patient  that  the  healthy  portions  of  the  organ  should  be  con- 
served. 

Contra-indications  to  Conservatism. — The  advanced  age  of  the  patient 
in  the  presence  of  diseased  tubes,  and  in  the  presence  of  pus,  malig- 
nancy, or  tuberculosis  at  any  age,  are  the  principal  contra-indications 
to  the  saving  of  a  portion  of  the  tubes. 

Radical  Surgical  Treatment. — Is  it  advisable  to  remove  the  healthy 
tube  in  the  presence  of  unilateral  salpingitis f  The  pioneer  worker  in 
surgery  of  the  uterine  appendages,  Lawson  Tait,  answered  this  question 
in  the  afiirmative.  Such  a  position  is  no  longer  tenable,  though  it 
applies  with  no  little  force  to  gonorrheal  and  tuberculous  salpingitis, 
inasmuch  as  these  infections  will  almost  invariably  attack  the  opposite 
tube.  The  practice  of  removing  the  apparently  healthy  tube  in  uni- 
lateral, gonorrheal,  and  tuberculous  salpingitis  is  the  more  permissible 
in  view  of  the  fact  that  the  tube,  which  to  the  naked  eye  is  apparently 
healthy,  may  be  the  seat  of  an  initial  infection.  Experienced  operators 
have  realized  the  truth  of  these  assertions  by  the  recurrence  of  the 
infection  in  the  tube,  which  was  not  removed  because  it  was  apparently 
normal  at  the  time  of  the  primary  operation. 

The  established  rule  is  to  remove  the  opposite  and  apparently  healthy 
tube  in  all  cases  of  unilateral  salpingitis  of  tuberculous  or  gonorrheal 
origin,  but  in  no  other  cases.  This  is  a  doubtful  rule  of  practice  in 
operating  upon  young  women. 


TREATMENT  OF  INFLAMMATORY  DISEASES  OF  TUBES     471 

Should  the  uterus  be  removed  together  with  the  tubes  in  bilateral  sal- 
yingitis't  In  answering  this  question  the  author  would  advance  the 
following  rules  for  the  guidance  of  the  surgeon: 

The  uterus  should  be  removed  together  with  the  inflamed  tubes: 

1.  ^Vhen  the  uterus  is  metritic  and  subinvoluted. 

2.  WThen  adhesions  bind  the  surrounding  viscera  to  the  uterus. 

3.  When  the  uterus  contains  myomata. 

4.  When  the  uterus  is  cancerous. 

5.  When  the  infection  is  tuberculous. 

In  young  women  I  am  constrained  to  be  more  conservative  in  dealing 
with  the  uterus  and  do  not  remove  it  when  its  walls  are  not  thickened 
and  extensive  adhesions  do  not  bind  the  uterus  to  neighboring  structures, 
and  finally,  when  a  part  or  all  of  the  ovaries  are  not  removed.  Thus 
atrophic  changes  do  not  follow,  the  menstrual  function  is  preserved, 
and  the  effect  upon  the  well-being  of  the  individual  is  the  best  that 
can  be  obtained.  While  such  is  the  author's  practice,  he  is  sometimes 
confronted  with  cases  which  persist  in  troublesome  leucorrhea  and 
menstrual  disorders  which  do  not  easily  respond  to  conservative 
treatment  and  may  eventually  demand  hysterectomy.  Notwithstand- 
ing these  disappointments,  he  is  of  the  opinion  that  the  uterus  should 
not  be  sacrificed  in  young  women  unless  there  is  evidence  of  a  deep- 
seated  infection  in  the  uterine  musculature  or  that  it  contains  other 
morbid  products,  such  as  fibroids  and  cancers,  which  in  themselves 
call  for  hysterectomy. 

From  a  surgical  point  of  view  the  removal  of  the  uterus  together  with 
the  inflamed  appendages  is  the  most  satisfactory.  Better  hemostasis 
is  obtained  by  securing  the  uterine  arteries;  raw  surfaces  are  diminished, 
drainage  is  more  readily  established,  and  the  duration  of  the  operation 
is  not  materially  lengthened.  It  is  sometimes  easier  to  remove  the 
uterus,  together  with  adherent  appendages,  than  to  dissect  out  the 
appendages  and  leave  the  uterus. 

The  suggestion  of  Kelly  is  worthy  of  consideration  in  this  respect. 
He  advises  the  removal  of  part  of  the  body  of  the  uterus  in  order  to 
retain  the  menstrual  function.  When  the  tubes  have  been  removed, 
but  not  all  of  the  ovaries,  a  heavy  uterus,  or  one  that  is  adherent  or 
contains  fibroid  tumors  in  the  fundus,  may  be  amputated  at  a  point 
above  the  external  os  and  thereby  preserve  the  capacity  of  menstruation. 
(See  page  442.) 

The  uterine  splitting  operation,  as  advocated  by  Howard  Kelly,  is 
applicable  to  those  cases  in  which  the  uterus,  together  with  the  distended 
tubes  and  ovaries,  are  firmly  matted  by  adhesions.  By  first  splitting 
the  uterus  in  the  median  line  and  removing  either  half  at  the  level  of 
the  internal  os,  the  adherent  appendages  can  be  readilv  attacked.  (See 
Figs.  332,  333,  334,  335,  336,  and  337.) 

Operative  Treatment. — When  conservative  treatment  of  the  inflamed 
tubes  has  failed  to  eftect  a  cure  and  the  patient  continues  to  be  distressed 
by  the  existing  lesion,  surgical  intervention  may  be  invoked. 


472 


FALLOPIAX    TUBES  AXD  OVARIES 

Fir..   332 


Uterine  splitting  operation.     The  uterus  is  grasped  at  either  horn  by  tenaeula.     A  vertical  incision 
is  made  in  the  median  line  .from  the  fundus  to  the  internal  o.s.     (Modified  from  Kelly.) 


Fig.  333 


Sj\\yU\\ 


The  body  of  the  uterus  is  amputated  on  the  right  side  at  the  cervical  juncture.  The  uterine  arterj- 
is  grasped  with  forceps,  cut.  and  ligated.  The  round  ligament,  ovarian  ligament,  and  Fallopian  tubes 
are  ligated  and  severed  near  their  attachments  to  the  uterus. 


TREATMENT   OF  INFLAMMATORY   DISEASES   OF   TUBES     473 


Fig.  SSi 


m^mfj^^m 


Both  halves  of  the  uterus  are  severed  from  the  cervix.  The  round  ligament.^,  tubes,  ovarian  liga- 
ments, and  uterine  arteries  are  secured  by  ligatures  preparatory  to  severing  all  attachments  of  the 
uterus. 

Fig.  335 


:'^^'Tj^^mmMwmrf^ 


The  bod3'  of  the  uterus  is  removed,  providing  free  access  to  the  enlarged  and  adherent  appendages. 


474 


FALLOPIAX   TUBES  AXD  OVARIES 

Fig.   336 


The  uterus  is  retroverted   and  firmly   adhered.     The  peritoneum  is  stripped   downward   from   the 
supravaginal  portion  of  the  cervix  preparatorj^  to  amputating  the  cervix  from  before  backward. 


Fig.  337 


%^x 


\*.--' 


z^^:?'"- 


->  / 


^ 


-^^'~^  -^^^y  .'/ ,... ^^/  "  ^  /^V  vj'  -/'^A'y^ 


The  uterus  is  amputated  at  the  cervix  and  is  bisected  from  below  upward.     The  remaining  steps 
of  the   operation  are  as  in  Figs.   333,    334,    335,   336. 


TREATMENT  OF  INFLAMMATORY  DISEASES  OF  TUBES     475 

The  belief  that  all  inflamed  tubes  call  for  operative  interference  is, 
happily,  no  longer  entertained  by  gynecologists.  They  have  learned  that 
some  of  these  tubes  undergo  spontaneoiis  healing,  and  that  not  a  small 
proportion  cease  to  give  serious  trouble  when  managed  conservatively. 
These  observations  have  led  the  profession  to  interfere  surgically  in 
salpingitis  only  after  conservative  measures  have  been  given  a  fair 
trial  and  without  avail. 

Catarrhal  Salpingitis. — In  the  acute  stage  of  catarrhal  salpingitis 
only  conservative  measures  should  be  practised.  The  patient  should 
be  confined  to  bed,  the  diet  restricted,  ice  applied  to  the  abdomen, 
the  bowels  regulated,  and  local  depletive  measures  employed.  Long 
hot  vaginal  douches,  given  at  intervals  of  four  to  eight  hours,  will  do 
much  to  allay  the  inflammatory  reaction. 

When  not  too  painful,  glycerin  and  ichthyol  vaginal  tampons  may 
be  effectively  applied.  These  should  be  applied  daily  for  six  to  eight 
hours.  Ordinarily  the  acute  stage  will  pass  in  three  to  five  days,  and 
the  tubes  either  return  to  normal  or  become  chronically  inflamed. 

No  surgical  intervention  should  be  instituted  in  the  acute  stage  of  catarrhal 
salpingitis  for  the  reason  that  a  cure  by  the  exercise  of  conservative 
measures  is  always  possible,  and  because  of  the  dangers  involved  in  an 
abdominal  operation  upon  tubes  containing  virulent  microorganisms. 
It  is  further  advised  to  avoid  so  far  as  possible  all  pelvic  manipulations 
in  such  cases,  for  fear  of  exciting  the  infection  to  extend  from  the  tubes 
to  the  peritoneum.  All  digital  and  instrumental  manipulations  should 
be  restricted  to  the  minimum,  and  all  intra-uterine  manipulations  should 
be  proscribed  unless  for  the  removal  of  placental  tissues  and  infected 
tumors. 

Chronic  Catarrhal  Salpingitis. — Conservative  measures  should  be 
instituted  in  the  treatment  of  chronic  catarrhal  salpingitis.  Hot 
vaginal  douches,  glycerin  and  ichthyol  tampons,  pelvic  massage,  and 
other  means  may  be  employed,  with  benefit;  but  when  given  a  fair 
trial,  and  without  affording  relief,  it  is  then  permissible  to  resort  to 
surgical  measures.  The  surgery  of  chronic  catarrhal  salpingitis  holds 
out  the  opportunity  for  the  exercise  of  conservatism.  It  is  not  impera- 
tive in  all  cases  that  all  of  one  or  both  tubes  should  be  removed.  It 
may  be  that  the  separation  of  the  matted  fimbriae  and  the  expressing 
of  contained  secretions  is  all  that  is  required. 

Again,  a  portion  of  the  tube  may  be  resected,  leaving  a  healthy 
portion  to  provide  for  the  possibility  of  childbirth. 

When  both  tubes  are  affected,  conservatism  should  be  practised. 

The  removal  of  one  or  both  tubes  is  imperative  when  the  uterine 
end  of  the  tube  is  so  disorganized  as  to  no  longer  functionate,  and  when 
the  ovaries  have  been  removed  or  are  incapable  of  carrying  on  their 
function.  There  is  not  the  need  of  exercising  conservatism  in  the 
surgery  of  the  tubes  when  it  is  apparent  that  sterility  is  inevitable. 

When  it  is  believed  that  pathogenic  microorganisms  exist  in  the  tube, 
it  is  not  safe  to  leave  a  portion.  For  the  technic  of  the  operation  see 
the  following  pages. 


476  FALLOPIAN  TUBES  AND  OVARIES 

Hydrosalpinx. — A  hydrosalpinx  may  exist  without  local  or  general 
disturbances,  and  in  such  cases  it  cannot  be  said  that  surgery  should 
be  invoked.  There  are  reasons,  however,  for  intervening  surgically 
which  are  worthy  of  consideration.  We  have  learned  that  hydrosalpinx 
is  sometimes,  if  not  frequently,  the  result  of  a  congenital  closure  of 
the  fimbriated  end  of  the  tube  with  subsequent  accumulation  of  the 
tubal  secretions.  When  bilateral,  sterility  is  the  result  and  relief  may 
be  possible  by  resecting  the  distended  portion.  This  is  only  possible 
when  the  distention  involves  the  distal  portion  of  the  tube  and  cannot 
be  considered  in  the  presence  of  other  and  irreparable  causes  of 
sterility. 

The  operative  treatment  for  hydrosalpinx  consists  in  the  removal 
of  part  or  all  of  the  distended  tube.  When  it  is  possible  to  leave  a 
portion  of  healthy  tube  this  should  be  done,  provided  other  conditions 
are  favorable  to  childbearing. 

When  the  tube  is  more  or  less  distended,  and  particularly  Avhen  there 
are  inflammatory  changes  in  and  about  the  tube,  the  complete  removal 
of  the  tube  should  be  made.  For  the  technic  of  salpingectomy  see 
page  478. 

Hematosalpinx. — As  a  general  proposition  a  hematosalpinx  should 
be  removed.  There  is,  however,  abundant  opportunity  for  exercising 
conservatism  in  the  saving  of  healthy  portions  of  the  tube.  This  should 
not  be  attempted  in  the  presence  of  infection  within  the  tube  and  of 
irreparable  lesions  of  the  ovaries  and  uterus. 

Chronic  Purulent  Salpingitis. — No  attempt  should  be  made  to  eradicate 
the  tube  during  the  acute  suppurative  stage,  and  operative  intervention 
in  the  chronic  stages  should  be  deferred  until  conservative  measures 
have  been  well  tried.  Rest,  hot  vaginal  douches,  poultices,  glycerin 
and  ichthyol  tampons  may  do  much  to  give  relief,  and  may  produce 
a  functional  cure,  and  should  be  given  an  extended  trial  before  resorting 
to  surgery.  If  no  improvement  follows  these  treatments,  operation 
is    indicated. 

Salpingitis  is  rarely  fatal,  hence  the  opportunity  is  at  hand  to  give 
conservative,  tentative  treatment  a  fair  trial. 

Efforts  to  empty  the  pus  through  the  uterus  by  curettage  and  massage 
are  to  be  condemned  as  futile  and  dangerous. 

Removal  of  the  entire  tube  is  the  only  alternative  when  tentative 
measures  have  been  tried  and  have  failed. 

Vaginal  Drainage  for  Pyosalpinx. — The  following  are  safe  and  reliable 
guides  in  the  management  of  pyosalpinx: 

1.  In  all  recent  accumulations  of  pus  within  the  tubes  which  call 
for  surgical  interference,  only  vaginal  drainage  should  be  considered. 

2.  In  all  old  accumulations  of  pus  within  the  tubes  which  are  favorably 
located  for  drainage  through  the  vagina,  the  safest  rule  to  follow  is  to 
establish  such  drainage  and  await  the  clearing  up  of  the  abscess  cavity 
before  proceeding  with  the  removal  of  the  tubes  through  an  abdominal 
incision. 

Vaginal  drainage  of  pus  located  in  the  tubes  is  not  a  simple  procedure 


T  RE  ATM  EXT  OF  INFLAMMATORY  DISEASES  OF   TUBES     4/7 

from  a  technical  point  of  view,  nor  is  it  a  safe  one  in  the  hands  of  the 
inexperienced.  Attempts  to  estabHsh  drainage  have  repeatedly  con- 
veyed the  infection  to  the  free  peritoneal  cavity,  and  with  fatal  results. 
The  author  views  the  operation  most  gravely,  and  particularly  so  in 
cases  of  acute  infection. 

It  has  happened  in  the  experience  of  the  operator  that  vaginal 
drainage  of  pus  tubes  has  brought  about  a  complete  and  lasting  func- 
tional cure  when,  had  the  abdominal  route  been  chosen,  the  tubes  and 
possibly  the  uterus  and  ovaries  woidd  have  been  sacrificed. 

Vaginal  drainage  is  feasible  when  the  patient  is  too  depressed  to 
withstand  the  shock  of  an  abdominal  operation.  Because  of  the  much 
lower  mortality  and  the  opportunity  afforded  for  the  preser\"ation  of 
tissues,  vaginal  drainage  is  greatly  to  be  preferred  to  the  more  radical 
abdominal  operation  in  all  cases  in  which  the  pus  can  be  readily  reached 
per  vaginam. 

Technic  of  Operation. — The  foUowing  is  the  usual  method  employed 
by  the  author:  After  thorough  sterilization  of  the  field  of  operation 
the  vagina  is  exposed  by  a  weighted  vaginal  speculum;  the  posterior 
lip  of  the  cervix  is  grasped  by  tenaculum  forceps  and  gentle  traction  is 
made  upward  and  outward  by  an  assistant.  The  operator  grasps  the 
vaginal  wall  close  to  its  reflection  upon  the  posterior  wall  of  the  cervix 
with  long  rat-tooth  tissue  forceps.  A  transverse  incision  is  made  with 
long  sharp-pointed  scissors  through  the  vaginal  wall  and  close  to  the 
cervix.  This  incision  is  about  one  inch  in  length.  The  finger  is  inserted 
through  the  incision,  and  by  a  gentle  stripping  and  boring  process 
the  finger  finds  its  way  in  the  direction  of  the  abscess.  "When  pus  is 
reached,  the  two  index  fingers  are  inserted  and  the  wound  stretched  to 
admit  of  free  drainage. 

When  the  pus  ceases  to  flow,  a  careful  exploration  of  the  peh'ic  ca^'ity 
should  be  made  to  detect  and  evacuate  other  accumulations  of  pus 
within  the  pelvic  cavity. 

^Mien  all  pus  cavities  have  been  evacuated  and  a  free  avenue  for 
subsequent  drainage  provided,  the  cavity  is  then  loosely  packed  with 
washed  iodoform  gauze.  This  pack  is  removed  at  the  end  of  forty- 
eight  hours  and  thereafter  the  cavity  is  irrigated  with  sterile  >alt 
solution. 

It  frequently  happens  that  drainage  is  not  always  free;  in  .-uch  event 
the  incision  should  be  spread  either  with  forceps  or  finger. 

The  following  precautions  should  be  noted: 

1.  Before  attempting  to  drain,  a  bimanual  examination  should 
be  made  to  determine  the  exact  size  and  location  of  the  abscess. 

2.  The  incision  should  be  made  close  to  the  cervix,  and  in  burrowing 
to  the  abscess  the  finger  should  be  kept  in  close  proximity  to  the  uterus 
for  fear  of  injuring  the  rectum. 

3.  The  greatest  caution  must  be  exercised  in  all  manipulations  for 
fear  of  liberating  pus  into  the  free  abdominal  cavity. 

4.  In  exploring  the  pelvis  with  the  finger  there  is  danger  of  perfor- 
ating a  loop  of  bowel  anrl  thereby  creating  a  distressing  fecal  fi-tula. 


478  FALLOPIAN  TUBES  AND  OVARIES 

5.  The  cavity  should  not  be  swabbed  with  gauze.  No  irrigation 
should  be  employed  for  fear  of  washing  infected  material  into  the 
abdominal   cavity. 

6.  Rubber  drainage  tubes  and  tightly  packed  gauze  are  dangerous 
in  view  of  possible  pressure  necrosis  of  the  bowel  wall. 

7.  When  the  abscess  lies  too  high  to  be  reached  by  the  finger,  an 
experienced  operator  may  pass  closed  dressing  forceps  in  advance  of 
the  finger.  The  forceps  are  passed  into  the  abscess  and  opened  to 
spread  the  perforation  in  the  abscess  wall.  In  the  hands  of  the  inex- 
perienced operator  this  is  a  dangerous  procedure. 

8.  If  the  infection  is  tuberculous,  nothing  short  of  a  radical  abdominal 
operation  will  eft'ect  a  cure,  and  this  should  be  done  after  the  pus  has 
well  drained. 

Tuberculous  Salpingitis. — The  author  believes  that  the  only  safe 
rule  to  follow  in  tuberculous  salpingitis  is  to  remove  the  affected  tubes. 
(For  further  discussion  see  page  542.) 

In  the  presence  of  a  general  peritoneal  involvement  the  effort  should 
be  made  to  remove  the  primary  focus,  which  in  a  large  percentage  of 
cases  is  found  in  the  tubes.  If  a  tuberculous  lesion  of  the  lungs  is  found 
not  to  be  so  far  advanced  as  in  itself  to  make  recovery  impossible,  this 
complication  should  not  deter  the  surgeon  from  eradicating  the  pelvic 
infection.  Having  removed  the  pelvic  infection  the  patient  should 
be  placed  under  favorable  hygienic  conditions,  such  as  are  prescribed 
for  tuberculosis  in  general. 

It  is  well  to  emphasize  the  importance  of  prophylaxis  in  genital 
tuberculosis.  It  is  known  that  the  infection  can  be  conveyed  by 
instruments  and  examining  fingers  and  by  the  tuberculous  husband; 
the  precautionary  measures  to  be  observed  are  self-evident. 

Technic  of  Operations  on  the  Tubes. ^ — ^Alien  adhesions  close  the 
abdominal  opening  or  bind  the  tube  to  surrounding  structures,  and  in 
the  absence  of  structural  changes  in  the  tube  wall,  these  adhesions 
may  be  carefully  severed,  leaving  the  tube  intact  and  in  the  normal 
position. 

Salpingostomy  or  Amputation  of  the  Tube  at  the  Isthmus  or  Ampullary 
Portion. — Two  points  should  be  emphasized  in  this  operation:  (1)  The 
artificial  opening  in  the  tube  must  closely  approximate  the  ovary,  and 
(2)  an  ectropion  of  the  tubal  mucosa  must  be  produced  by  stitching 
the  mucosa  to  the  peritoneal  covering  of  the  tube.  This  is  done  by 
plain  sterile  catgut  No.  1. 

This  procedure  is  not  without  some  danger.  Cases  have  been  reported 
in  which  postoperative  hemorrhage  has  occurred,  and  infection  from  the 
tube  has  followed,  and  the  newly  formed  osteum  has  again  closed  by 
adhesions. 

Salpingectomy  or  Removal  of  the  Tube. — ^The  tube  may  be  removed 
either  by  the  abdominal  or  vaginal  route. 

By  the  Ahdominal  Route. — The  usual  suprapubic,  mesial  incision  is 
made.  Adhesions  binding  the  tube  may  be  broken  by  the  fingers  or 
severed  by  scissors  under  the  guidance  of  the  eye.    With  long  forceps 


TREATMENT  OF  INFLAMMATORY  DISEASES  OF  TUBES     479 

the  infundibulopelvic  ligament  may  then  be  grasped  and  the  tube 
deHvered  into  the  abdominal  incision.  If  firm  adhesions  bind  the  tube 
to  the  bowel  it  may  be  necessary  to  strip  off  the  peritoneal  covering 
of  the  tube,  together  with  the  bowel,  to  prevent  injury  to  the  bowel 
wall.  A  No.  2  plain  catgut  ligature  is  made  to  transfix  the  infundibulo- 
pelvic ligament,  taking  care  not  to  embrace  the  ovarian  vessels  if  the 
ovary  is  to  be  left  intact. 

Holding  the  tube  with  fingers  or  forceps,  the  attachments  of  the  tube 
are  severed  with  scissors  from  within  the  ligature  placed  about  the 
infundibulopelvic  ligament,  and  passing  along  the  attachment  of  the 
tube  to  the  broad  ligament  to  the  uterine  cornua.  The  tube  is  then 
dissected  from  the  horn  of  the  uterus  with  a  knife.  All  bleeding  points 
are  to  be  secured  by  forceps. 

In  purulent  salpingitis  it  is  best  to  amputate  the  tube  from  the  uterus 
by  the  actual  cautery.  The  severed  broad  ligament  and  open  cornua 
of  the  uterus  are  then  sutured  with  catgut.  With  a  running  suture  of 
No.  1  plain  catgut  all  bleeding-points  are  secured  and  raw  surfaces  are 
covered. 

When  the  tube  is  adhered  to  the  floor  of  the  pelvis  it  is  best  to  proceed 
with  the  excision  at  the  horn  of  the  uterus. 

If  the  tube  is  greatly  distended  with  pus  and  adherent,  so  that  there 
is  great  liability  of  rupturing  the  tube,  it  is  best  to  aspirate  the  contents 
before  attempting  to  remove  it. 

After  completing  the  operation  the  abdomen  is  closed  without 
drainage,  unless. pus  has  been  set  free  in  the  operation  and  much  raw 
surface  has  been  created  by  the  severing  of  adhesions.  When  found 
necessary  to  drain,  the  proper  procedure  is  to  open  through  the  cul- 
de-sac  into  the  vagina,  pass  a  strip  of  sterile  or  antiseptic  gauze  through 
this  opening  into  the  vagina,  and  pack  the  remaining  portion  of  the 
gauze  loosely  in  the  pelvis,  then  to  close  the  abdominal  incision.  At 
the  end  of  forty-eight  hours  the  gauze  is  removed  through  the  vagina. ' 
When  the  drainage  is  done  for  a  safeguard  against  infection  the  patient 
should  be  placed  for  several  days  in  the  Fowler  position. 

When,  by  the  removal  of  the  tube,  the  uterus  has  lost  part  of  its 
support  the  round  ligament  should  be  brought  over  the  horn  of  the 
uterus  and  stitched  to  the  posterior  surface.  This  procedure  serves 
the  double  purpose  of  maintaining  the  uterus  in  its  proper  position 
and  of  covering  the  raw  surface  at  the  cornua. 

When  the  ovary  is  diseased  it  is  to  be  removed  in  part  or  in  toto, 
according  to  the  rules  laid  down  in  the  following  chapter. 

By  the  Vaginal  Route. — In  the  past  too  great  enthusiasm  has  appar- 
ently been  displayed  in  operating  through  the  vagina  upon  the  uterine 
appendages.  In  some  cases  this  may  be  done  satisfactorily,  but  when 
extensive  adhesions  exist  the  procedure  is  at  best  hazardous.  The 
danger  of  injuring  the  bowel,  of  creating  uncontrollable  hemorrhage, 
and  of  leaving  a  diseased  vermiform  appendix  are  sufficient  to  condemn 
the  operation  in  such  cases.  An  imperfect  recovery  is  sometimes 
obtained,  due  to  the  extensive  raw  surfaces  left,  which  lead  to  the 


480  FALLOPIAN  TUBES  AND  OVARIES 

formation  of  adhesions.  In  addition  to  these  arguments  in  favor  of 
the  abdominal  route  is  the  greater  degree  of  safety  in  abdominal  opera- 
tions which  are  performed  under  the  guidance  of  the  eye. 

Hysterectomy  in  connection  with  the  removal  of  badly  infected 
appendages  is   much   in   vogue,   and   is  discussed   on   page  471. 

CIRCULATORY  DISTURBANCES  IN  THE  OVARY 

Etiology. — There  is  a  physiological  hyperemia  of  the  ovary  during 
menstruation,  coition,  and  pregnancy.  The  ovaries  share  in  a  general 
pelvic  congestion,  hence  all  embarrassments  to  the  general  circulation 
from  diseases  of  the  heart,  lungs,  kidney,  and  liver,  from  abdominal 
tumors,  collections  of  fluid  in  the  abdomen,  and  constipation  will 
cause  passive  congestion  of  the  ovaries. 

In  certain  hemorrhagic  diseases,  such  as  scorbutus  and  purpura, 
there  are^  hemorrhages  into  the  substance  of  the  ovaries.  Hyperemia 
of  the  ovary  is  an  accompaniment  of  all  the  inflammatory  lesions  in 
the  pelvis.  The  more  acute  the  lesion  the  greater  the  hyperemia.  As 
remarked  in  the  section  on  Descensus  Ovarii,  the  ovary  is  congested. 

Anatomical  Diagnosis. — In  hyperemia  of  the  ovary  there  is  a  slight 
increase  in  size  in  all  diameters  and  a  more  livid  color.  Following 
long-standing  hyperemia  there  is  an  increase  of  the  connective  tissue. 
The  tunica  albuginea  is  thickened  and  the  follicles,  failing  to  rupture 
through  the  thick  and  resisting  tissue,  lead  to  follicular  degeneration 
of  the  ovary. 

Fig.  338 


Hematoma  of  the  ovary.     (Hertzler.) 


Hematoma  of  the  Ovary. — Hematoma  of  the  ovary  is  often  of  obscure 
origin.  It  is  possible  for  hemorrhages  to  occur  in  the  ovary  as  the 
result  of  any  of  the  above-named  causes  for  hyperemia.    As  an  under- 


CIRCULATORY  DISTURBANCES  IN  THE  OVARY 


481 


lying  factor  there  may  be  degenerative  changes  in  the  bloodvessels 
of  the  ovary.  Such  collections  of  blood  are  usually  found  in  the  follicles; 
hemorrhages  into  the  interstitial  spaces  are  less  common.  Virchow 
and  Olshausen  each  report  a  case  complicating  scorbutus.  Torsion  of 
the  tube  and  ovarian  ligament  may  cause  hemorrhages  into  the  stroma 
and  follicles  of  the  ovary. 

Martin  reported  109  cases  in  which  blood  collections  in  the  ovaries 
varied  in  size  from  that  of  a  bean  to  a  man's  fist.  Of  this  number  25 
were  between  the  ages  of  eighteen  and  fifty-two;  22  were  not  married; 
the  right  ovary  was  affected  47  times,  the  left  55  times,  and  both 
ovaries  32  times.  In  all  but  8  cases  there  was  more  or  less  peritonitis, 
and  4  of  the  8  had  uterine  fibroids,  1  chlorosis,  2  endometritis  and 
metritis,  and  1  practised  masturbation.  In  26  of  the  109  cases  a  trau- 
matic cause  could  be  traced  in  the  history,  such  as  the  passing  of  the 
uterine  sound,  the  wearing  of  pessaries,  and  the  replacing  of  the  uterus. 
Hematoma  is  an  unusual  finding  in  an  otherwise  perfectly  normal  ovary. 
Any  of  the  new  formations  and  inflammatory  lesions  may  accompany 
hematoma. 

Fig.  339 


Hematoma  of  the  corpus  luteum.     The  ovary  is  greatly  hypertrophied,  and  at  the  distal  end  is  a 
single  protruding  blood  cyst  the  size  of  an  English  walnut,  formed  from  a  corpus  luteum. 

Hemorrhages  into  the  substance  of  the  ovary  are  found  in  one  or 
more  of  three  places:  in  the  follicles,  corpus  lufeum,  or  connective-tissue 
spaces. 

1.  Hemorrhages  into  the  follicles  may  distend  them  to  the  size  of  a 
man's  fist.  More  than  a  single  follicle  may  be  involved.  The  stretched 
walls  of  the  follicles,  with  their  contained  blood,  have  a  bluish  tint. 
The  contained  blood  may  or  may  not  be  coagulated,  and  is  dark  red  or 
grayish  brown.  The  inner  surface  of  the  follicles  is  smooth,  though 
occasionally  made  uneven  by  coagulated  blood  adhering  to  the  wall. 
Fatty  degeneration  of  the  epithelium  lends  a  yellowish  tint  to  the 
31 


482  FALLOPIAX  TUBES  AXD  OVARIES 

inner  surface.  The  contained  blood  may  be  wholly  absorbed  or  con- 
verted into  fibrin,  which,  by  contracting,  may  obliterate  the  follicles. 
Occasionally  the  follicle  bursts,  and  the  blood  escapes  into  the  peritoneal 
cavity. '  The  escaped  blood  has  been  known  to  set  up  a  peritonitis, 
and  cases  are  recorded  in  which  the  hemorrhage  was  fatal.  Infection 
of  the  blood  may  give  rise  to  abscess  formation  in  the  ovary. 

2.  Hemorrhages  into  the  corpus  lideum  are  identified  by  the  corru- 
gated lining  membrane  of  lutein  cells  or  by  their  granular  appearance. 
Such  bodies  are  single,  and  are  located  in  the  periphery  of  the  ovary. 
Hematoma  of  the  corpus  luteum  has  been  known  to  attain  the  size 
of  a  child's  head. 

In  the  hematoma  of  the  corpus  luteum  the  wall  is  more  congested 
and  thicker  than  in  the  preceding  variety.  On  the  inner  surface  of  the 
cyst  there  is  a  deposit  of  fibrin,  in  the  meshes  of  which  are  disintegrated 
blood  and  small  round  cells.  Beneath  this  are  the  lutein  cells,  varying 
in  number,  size,  and  form  according  to  the  age  and  size  of  the  hematoma. 
External  to  the  lutein  cells  is  the  tunica  externa,  composed  of  fibrous 
tissue. 

3.  Hemorrhage  into  the  connective-tissue  spaces  is  less  comrnon.  Such 
hemorrhages  are  often  midtiple,  and  are  seldom  of  large  size.  Multiple 
punctate  hemorrhages  may  be  distributed  through  the  stroma  and 
add  materially  to  the  size  of  the  ovary. 

The  blood  is  found  in  various  stages  of  preservation.  In  follicular 
hematoma  the  epithelium  lining  the  blood  cyst  may  be  well  preserved, 
assuming  a  variety  of  shapes  from  cylindrical  to  flattened.  Several 
layers  may  be  found.  In  the  larger  hematomata  there  may  be  but  a 
single  layer  of  flat  epithelium,  and  even  this  may  partially  or  wholly 
disappear  through  pressure  atrophy.  Blood  extravasations  and  con- 
gested bloodvessels  may  be  seen  in  the  tunica  propria. 

Clinical  Diagnosis. — There  may  be  no  clinical  manifestations.  The 
ovary  is  usually  tender  to  pressure.  Pain  in  the  ovary  may  radiate 
to  the  back  and  thighs.  The  pain  is  at  its  height  during  the  period  of 
premenstrual  congestion,  and  abates  when  a  free  flow  is  established. 

It  has  been  said  that  when  pelvic  congestion  is  present  and  a  throbbing 
pain  develops  in  the  ovary,  with  no  elevation  of  temperature,  it  is  to 
be  inferred  that  a  hematoma  has  developed  in  the  ovary.  A  diagnosis 
can  only  be  made  on  exploration  of  the  ovary. 

In  a  bimanual  examination  the  ovary  is  invariably  found  enlarged, 
though  it  is  seldom  larger  than  a  walnut.  The  consistency  is  tense 
and  elastic. 

Although  sharply  circumscribed  the  ovary  is  usually  irregular  in 
outline.  It  is  found  on  a  lower  level  than  normal,  often  lying  low 
beside  or  behind  the  uterus. 

It  is  difficult  and  often  impossible  to  difterentiate  hyperemia,  hema- 
toma, and  inflammation  of  the  ovary.  The  pain  and  tenderness  may 
be  equally  intense,  and  there  may  be  no  distinction  in  the  physical 
findings.  In  inflammation  the  symptoms  are  usually  of  longer  standing 
and  more  pronounced.    The  history  of  the  onset  should  be  considered. 

Treatment. — (See  Treatment  of  Ovarian  Tumors.) 


INFLAMMATION  OF  THE  OVARY  483 


INFLAMMATION  OF  THE  OVARY  (OOPHORITIS,   OVARITIS). 

For  practical,  clinical  purposes  inflammations  of  the  ovary  will  be 
classified  as  acute  and  chronic. 

Acute  Ovaritis. — x\cute  inflammation  of  the  ovary  is  due  to  direct 
invasion  of  the  ovary  by  bacteria  or  to  the  influence  of  their  toxic 
products.  Certain  inorganic  poisons  (phosphorus,  arsenic)  act  in  a 
similar   manner. 

All  the  infectious  diseases  may  be  complicated  by  o^•aritis,  including 
the  exanthemata,  typhoid  fever,  cholera,  pneumonia,  influenza,  dysen- 
tevy,  wound  infections,  gonorrhea,  and  tuberculosis. 

The  microorganisms  found  in  the  ovary  under  such  conditions  are 
staphylococci,  streptococci,  pneumococci,  gonococci,  typhoid  bacilli, 
and  actinom\'ces. 

In  all  the  above-named  causes  of  ovaritis  the  same  general  anatomical 
changes  follow,  there  being  no  essential  difference  in  the  anatomy  of 
the  various  etiological  forms. 

Pfannenstiel  considers  acute  ovaritis  under  the  heads  of  septic  and 
gonorrheal. 

Acute  Septic  Ovaritis. — Acute  septic  ovaritis  is  a  complication  of 
puerperal  sepsis,  but  a  similar  lesion  may  arise  from  the  non- puerperal 
septic  agencies  above  named. 

The  ovar}'  is  uniformly  enlarged  and  reddened,  and  the  stroma  becomes 
infiltrated  with  a  serous  exudate  and  small  round  cells.  The  follicular 
epithelium  degenerates,  the  ovum  dies  and  is  absorbed,  and  the  liquor 
folliculi  becomes  turbid,  h'uppuration  may  follow,  leading  to  the 
formation  of  abscesses  in  the  corpus  luteum,  follicles,  and  interstitial 
spaces. 

Resolution  is  the  rule,  and  this  is  possible  either  by  complete 
absorption  of  the  exudate,  leaving  the  ovary  in  a  normal  condition,  or 
by  atrophy  of  the  connective  tissue,  with  its  subsequent  contraction. 

Acute  Gonorrheal  Ovaritis. — Acute  gonorrheal  ovaritis  is  rarely 
primary,  and  is  almost  invariably  secondary  to  salpingitis.  In  excep- 
tional cases  the  infection  is  conveyed  from  the  cervix  through  the 
lymphatics  of  the  broad  ligaments  to  the  hilum  of  the  ovary. 

Wertheim  has  succeeded  in  demonstrating  the  gonococcus  in  the 
ovary. 

Chronic  Ovaritis. — Chronic  ovaritis  is  a  clinical  term  designating 
a  long-standing  lesion  of  the  ovary,  characterized  by  hyperplasia  of 
the  stroma  and  secondary  atrophy  of  the  parenchyma. 

Chronic  ovaritis  may  be  the  terminal  stage  of  an  acute  infection  of 
the  ovary.  Any  condition  causing  prolonged  congestion  of  the  ovary 
will  result  in  chronic  ovaritis,  such,  for  example,  as  sexual  excesses, 
menstrual  congestion,  subinvolution,  malpositions  of  the  uterus, 
habitual  constipation,  incompetency  of  the  cardiovascular  system, 
pelvic  and  abdominal  tumors,  and  disorders  of  the  organs  of 
digestion. 


484 


FALLOPIAN  TUBES  AND  OVARIES 


Cystic  Degeneration  of  the  Ovaries. — It  may  now  be  fairly  stated 
that  the  profession  in  general  has  come  to  regard  cystic  degeneration 
of  the  ovaries  in  a  less  serious  light  than  was  first  presented,  but  yet 
accords  the  lesion  its  rightful  place  among  the  morbid  conditions  of 
the  ovarv. 


Fig.  340 


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— .^ 

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Jp<l;SiM»M*-SiJ^    ^ 

m^ 

tgk 

■  w 
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^ 

Chronic  ovaritis  with  folUcular  degeneration. 


I  have  made  microscopic  and  clinical  studies  of  180  cases  in  which 
one  or  both  ovaries  were  removed  or  resected  for  follicular  degeneration. 
Of  the  180  cases,  160  were  operated  by  Dr.  J.  Clarence  Webster;  20  by 
the  author;  only  39  of  these  cases  were  uncomplicated.  In  141  of  the 
cases  the  ovaries  were  operated  in  connection  with  other  lesions.  My 
observations  have  extended  over  a  period  of  twenty- two  months.  From 
the  clinical  records  I  have  tabulated  the  clinical  signs  which  appeared 
to  be  directly  referable  to  the  ovary.  In  this  I  met  with  difficulty 
because  of  the  frequent  presence  of  associated  lesions  which  often 
masked  those  ordinarily  ascribed  to  the  ovary.  In  many  instances  it 
was  not  possible  to  say  that  the  cystic  ovaries  contributed,  to  the 
symptom-complex  because  of  the  presence  of  more  serious  lesions. 

After  the  removal  of  all  existing  lesions,  and  relief  from  all  symp- 
toms obtained,  it  is  not  always  possible  to  say  to  what  extent  the 
resection  or  removal  of  the  ovaries  contributed  to  the  recovery.  For 
example,  cystic  degeneration  of  the  ovaries  associated  with  salpingitis 


INFLAMMATION  OF  THE  OVARY 


485 


and  retroversion  of  the  uterus  with  adhesions,  might  give  rise  to  back- 
ache, sterility,  and  dysmenorrhea,  and  contribute  to  general  nervous 
phenomena;  but  it  is  manifestly  impossible  to  determine  to  what  extent 
the  ovaries  contributed  to  the  suffering  and  disability.  However,  it 
may  be  expected  that  anatomical  and  clinical  studies  of  a  large  number 
of  these  cases  would  yield  some  valuable  suggestions,  and  especially 
so  when  compared  with  similar  studies  of  uncomplicated  cases. 


Fig.  341 


Follicular  degeneration  of  the  ovary.  The  ovary  contains  one  large  follicular  cyst  and  numerous 
small  ones.  The  stroma  is  increased  and  prevents  the  rupture  of  the  cysts.  Near  the  outer  border 
of  the  ovary  is  an  old  corpus  luteum.    The  cysts  contain  a  clear  serous  fluid. 

In  reviewing  the  opinions  of  the  observers  who  have  written  upon 
the  subject,  including  Virchow,  Gebhard,  Abel,  Kolb,  Ziegler,  Ruge, 
Pfannenstiel,  Amann,  Martin,  and  Frakle,  I  find  it  to  be  the  consensus 
of  opinion  that  follicular  degeneration  is  the  result  of  chronic  ovaritis; 
that  these  follicles  do  not  arise  from  cell  inclusions,  as  stated  by  Nagel, 
but  are  the  direct  result  of  passive  congestion  and  hyperplasia  of  the 
stroma. 

As  a  suggestion  of  the  pathological  nature  of  follicular  cysts,  Martin 
observes  that  they  are  not  confined  to  the  outer  zone  of  the  ovary, 
as  is  the  case  with  ripened  follicles,  but,  on  the  contrary,  are  distributed 
throughout  the  stroma.  This  he  regards  as  of  greater  significance  than 
the  number  and  size  of  the  follicles.  Martin  does  not  attempt  to  fix 
the  normal  limits  in  size  for  a  follicle,  but  says  they  are  manifestly 
pathological  when  they  approach  the  ovary  in  size,  whether  they 
contain  ova  or  not. 

Ziegler  described  a  follicular  cyst  the  size  of  a  man's  head,  and 
Martin  reports  one  which  weighed  seventeen  pounds. 

In  the  180  cases  of  cystic  degeneration  of  the  ovaries  in  which  com- 
plete or  partial  removal  of  one  or  both  ovaries  was  done  the  following 


486 


FALLOPIAN   TUBES  AND  OVARIES 


anatomical  conditions  were  noted :  the  cysts  varied  in  size  from  a  pea 
to  an  Eng'ish  walnnt,  and  in  number  from  one  to  a  score  or  more. 

Reference  to  the  diagrams  in  Fig.  342  shows  that  these  cysts,  as 
Martin  has  pointed  out,  are  not  confined  to  the  periphery  of  the  ovary, 
as  is  the  case  with  ripened  folUcles,  but  are  distributed  throughout 
the  stroma  and  may  almost  replace  the  stroma. 

On  microscopic  examination  of  these  ovaries  I  have  been  astonished 
to  note  the  scarcity  of  normal  follicles  which  contained  ova.  In  a 
few  sections  none  w^as  to  be  found,  and  in  nearly  all  they  were  fewer 
in    number  than  would   appear  normal.     The   explanation   probably 


Fig.   342 


Follicular  degeneration  of  the  ovary.    The  diagrams  illustrate  the  distribution  of  the  follicular  cysts 
throughout  the  stroma  of  the  07ary.     Almost  the  entire  ovary  is  replaced  by  the  cysts. 


lies  in  the  atresia  brought  about  by  the  addition  of  new  connective 
tissue  to  the  stroma  and  its  subsequent  contraction.  In  a  small  per- 
centage of  cases  fresh  corpora  lutea  were  found,  showing  the  ovary 
capable  of  functionating.  In  all  of  them  corpora  albicantes  were 
abundant. 

Hyaline  degeneration  is  a  prominent  feature  in  nearly  all  sections. 
The  walls  of  bloodvessels,  corpora  albicantes,  stroma,  and  tunica 
albuginea  all  possess  more  or  less  of  a  hyaline  deposit.  This  is  marked 
even  in  the  ovaries  of  young  individuals.  Congestion  of  the  blood- 
vessels, while  not  constant,  was  a  notable  feature  in  almost  all  cases. 
Round-cell  infiltration  of  the  stroma  was  frequently  observed. 


INFLAMMATION  OF  THE  OVARY  487 

Gland-like  structures,  the  remains  of  Gartner's  ducts,  were  occa- 
sionally found  in  the  hilus  of  the  ovary.  In  the  follicles,  not  exceeding 
a  pea  in  size,  the  membrana  granulosa  and  ovum  were  usually  found, 
and  when  present  the  ovum  was  never  in  a  healthy  state.  In  the  larger 
cysts  the  author  has  carefully  searched  for  lutein  cells  in  the  walls, 
but  has  repeatedly  failed,  and  in  many  there  w^as  a  trace  of  mem- 
brana granulosa  and  theca.  Cysts  the  size  of  a  walnut  were  undoubtedly 
follicular,  though  a  larger  number  were  from  corpora  lutea. 

A  review  of  the  clinical  history  of  these  180  cases  includes  the  records 
of  the  pathological  findings  at  the  time  the  operation  was  made,  with 
a  view  of  determining  to  what  extent  these  morbid  changes  in  the 
ovary  contributed  to  the  suffering  of  the  patient,  and  for  the  purpose 
of  determining  if  possible  the  clinical  importance  of  the  lesion. 

Of  the  180  cases,  39  were  uncomplicated  by  pelvic  lesions  other 
than  follicular  degeneration  of  the  ovaries.  A  clinical  study  of  these 
uncomplicated  cases  should  afford  some  definite  conclusions.  In  the 
remaining  141  cases  in  which  there  were  complicating  pelvic  lesions, 
it  has  been  possible,  to  a  certain  extent,  to  note  the  role  played  by  the 
cystic  ovaries,  but  this  was  onl\'  attempted  after  a  careful  analysis 
of  the  uncomplicated  cases. 

In  the  39  uncomplicated  cases  general  pelvic  pains  were  complained 
of  in  16;  pain  in  the  region  of  the  left  ovary  in  11;  pain  in  the  region 
of  the  right  ovary  in  10,  and  pain  in  the  back  in  19  cases.  It  was  a 
rule,  to  which  there  were  a  number  of  exceptions,  that  the  pain  was 
referred  to  the  affected  ovary.  When  both  ovaries  were  involved,  the 
pain  was  likely  to  be  distributed  throughout  the  pelvis,  and  when  one 
or  both  ovaries  were  cystic  and  \d,y  behind  the  uterus,  there  was  usually 
backache.  In  each  case  pelvic  pain  was  complained  of.  Tenderness 
was  almost  always  elicited  by  pressure  upon  the  afi'ected  ovaries.  In 
18  of  the  39  cases  there  was  dysmenorrhea,  and  in  the  most  of  these 
cases  the  pain  preceded  the  appearance  of  the  menstrual  flow  and 
continued  throughout  the  period. 

In  34  cases  the  flow  was  normal  or  decreased  in  amount;  in  5  cases 
there  was  menorrhagia;  (3  of  the  cases  were  sterile;  G  were  married,  and 
the  remaining  27  had  borne  from  one  to  nine  children.  In  3  cases 
it  is  recorded  that  the  patient  was  hysterical,  and  in  11  cases  general 
nervous  disturbances  were  complained  of.  Headache  was  present 
in  15  cases. 

In  reviewing  the  histories  of  the  141  complicated  cases,  the  author  has 
satisfied  himself  in  many  instances  that  the  cystic  ovaries  contributed 
in  the  above  manner  to  the  discomfort  of  the  individual. 

Varicose  ovarian  veins  in  the  broad  ligaments  are  doubtless  a  more 
common  factor  in  the  causation  of  cystic  degeneration  of  the  ovaries 
than  would  be  inferred  from  these  statistics.  Doubtless  they  were 
not  always  recorded  when  found,  and  the  Trendelenburg  position 
would  empty  the  veins  and  make  them  less  prominent.  The  passive 
congestion  in  the  ovaries  as  the  direct  result  of  varicosities  in  the 
ovarian  veins  would  lead  in  time  to  hydrops  of  the  follicles,  and  the 


FALLOPIAN  TUBES  AND  OVARIES 


hyperplasia  of  the  stroma  would  hinder  the  rupture  of  the  enlarged 
follicles. 

The  average  age  of  the  cases  when  operated  was  thirty-two  years. 
The  youngest  was  nineteen  years  and  the  oldest  forty-eight  years.  The 
greatest  number  were  operated  on  between  thirty  and  forty  years 
of  age,  but  there  was  an  almost  equal  number  between  twenty  and 
thirty  years.  The  usual  infectious  diseases  of  childhood  were  experi- 
enced in  65  per  cent,  of  the  180  cases;  and  there  was  a  history  of 
puerperal,  postabortive,  or  gonorrheal  infection  in  63  per  cent.  The 
average  duration  of  the  symptoms  was  seven  years.  These  observations 
have  led  me  to  the  following  conclusions: 


Follicular  cyst  of  the  ovary.     (Hertzler.) 


1.  Cystic  degeneration  of  the  ovaries  is  almost  invariably  the  result 
of  chronic  ovaritis,  which  in  turn  is  caused  by  infection  or  passive 
congestion  of  the  ovary.    It  is,  therefore,  a  morbid  lesion. 

2.  One  or  more  ripened  follicles  in  the  ovary  are  not  to  be  mistaken 
for  follicular  degeneration. 

3.  SjTnptoms  referable  to  cystic  degeneration  of  the  ovaries  are 
pelvic  pain  and  tenderness,  dysmenorrhea,  sterility,  and  general  nervous 
phenomena.  Of  these  symptoms,  pain  is  of  constant  occurrence,  but 
is  not  constant  in  character  or  location.  Too  much  stress  is  not  to  be 
laid  upon  the  complaint  of  pain  and  tenderness,  for  undoubtedly  the 
explanation  frequently  lies  in  the  presence  of  associated  lesions  or  in  an 
instability  of  the  general  nervous  system. 

4.  Cystic  degeneration  of  the  ovaries  doubtless  contributes  to  a 
general  nervous  state,  but  in  my  judgment  this  can  only  be  due  to  the 
local  discomfort.  I  doubt  if  there  can  exist  a  general  disturbance  of 
the  nervous  system  referable  to  the  ovaries  without  local  discomfort. 


INFLAMMATION  OF  THE  OVARY  489 

Therefore,  in  the  absence  of  local  disorders,  the  general  nervous  phe- 
nomena should  not  call  for  surgical  intervention  or  for  any  interference 
with  the  ovaries. 

Abscess  of  the  Ovary. — There  are  acute  and  chronic  abscesses  of 
the  ovary. 

1.  Acute  Abscess  of  the  Ovary. — Acute  abscess  of  the  ovary  is  seldom 
recognized  in  a  clinical  examination.  Such  abscesses  commonly  arise 
in  the  course  of  acute  general  septic  infections  with  a  speedy  fatal 
termination.  Hence  it  is  that  acute  abscesses  of  the  ovary  are  generally 
discovered  in  a  postmortem  examination. 

2.  Chronic  Abscess  of  the  Ovary. — Menge,  in  33  cases  of  ovarian 
abscesses,  found  the  gonococcus  in  9,  the  colon  bacillus  in  4,  the  strepto- 
coccus in  1,  saprophytic  anaerobic  microorganisms  in  1,  and  in  18 
the  pus  was  found  sterile.  Martin  found  the  pus  sterile  in  20  out  of 
55    cases. 

Fig.  344 


Follicular  cyst  of  the  ovary.     Cross-section.     (Hertzler,) 

Anatomical  Diagnosis.— As  in  hematoma,  so  in  abscess  of  the  ovary, 
there  are  three  localities  in  which  they  may  develop — the  interstitial 
spaces,  the  follicles,  and  the  corpus  luteum. 

Interstitial  abscesses  are  found  in  all  portions  of  the  ovary.  They 
are  usually  multiple  and  irregular  in  outline.  The  wall  of  the  abscess 
is  composed  of  connective  tissue  infiltrated  with  small  round  cells. 

Follicular  abscesses  usually  present  a  smooth  wall  of  connective 
tissue.  They  may  be  single  or  multiple,  and  may  attain  the  size  of 
a  man's  head. 

Corpus  luteum  abscesses  are  recognized  by  the  corrugated  inner 
lining  of  the  cyst  wall.  The  abscess  lies  superficially  and  is  usually 
single.  The  blood  coagulum  in  the  centre  of  a  corpus  luteum  is  a 
favorable  nidus  for  pyogenic  microorganisms.  This,  with  the  superficial 
position  of  the  corpus  luteum  and  its  intimate  connection  with  an 
infected  tube,  makes  infection  easily  possible. 

Tuboovarian  abscess,  by  which  is  understood  a  pyosalpinx  directly 
communicating  with  an  ovarian  abscess,  may  be  primary  or  secondary. 


490  FALLOPIAX   TUBES  AXD  OVARIES 

A  primary  tuboovariaii  abscess  begins  as  a  pyosalpinx  and  an  ovarian 
abscess,  and  later  communicates  and  forms  one  continuous  abscess 
ca^'ity.  A  secondary  tuboovarian  abscess  arises  from  a  secondary 
infection  of  a  primary  tuboovarian  cyst.  In  110  cases  of  ovarian 
abscesses  Martin  found  a  tuboovarian  abscess  in  18. 

Clinical  Diagnosis  of  Ovaritis. — The  clinical  picture  is  a  variable 
one.  The  ovary  is  seldom  involved  alone,  hence  the  clinical  picture 
of  ovaritis  is  rarely  observed  independent  of  complicating  inflammatory 
lesions. 

Acute  ovaritis  causes  a  rise  of  temperature  and  increase  in  the  pulse- 
rate.  There  is  exquisite  tenderness  on  pressure  over  the  ovary,  so  much 
so  that  an  anesthetic  is  required  in  palpating  it.  For  practical  purposes 
a  diagnosis  of  acute  inflammation  of  the  adnexa  is  sufficient.  "When 
the  acute  stage  of  the  inflammation  has  subsided,  the  ovary  can  be 
outlined  by  a  bimanual  examination. 

In  chronic  ovaritis  there  is  no  elevation  in  temperature.  Pain  in  the 
region  of  the  aftected  ovary,  radiating  to  the  groin  and  thigh,  is  the  most 
constant  symptom.  Occasionally  the  pain  recurs  at  regular  intervals 
between  the  menstrual  periods  ("^Mittelschmertz").  The  explanation 
of  this  phenomenon  is  the  ripening  and  bursting  of  the  follicles  through 
the  resisting  stroma  and  tunica  albuginea.  Individuals  show  a  marked 
difference  in  their  susceptibility  to  pain. 

Chronic  ovaritis  may  exist  to  a  marked  degree  without  causing  pain, 
while,  on  the  other  hand,  a  slight  involvement  of  the  ovary  may  cause 
intense  suffering.  The  pain  is  aggravated  during  the  period  of  pre- 
menstrual and  menstrual  congestion.  The  pain  of  chronic  ovaritis 
is  often  but  the  expression  of  a  general  nerve  storm,  and  it  is  often 
difficult,  indeed,  to  determine  just  how  much  the  lesion  in  the  ovary 
has  to  do  with  the  pain. 

In  the  early  stage  of  chronic  ovaritis  the  menses  are  increased,  but, 
as  the  true  ovarian  tissue  gives  place  to  connective  tissue,  the  menses 
become  more  and  more  scanty.  Sterility  is  a  common  complaint,  and 
is  the  immediate  result  of  such  complicating  lesions  as  salpingitis  and 
endometritis  more  often  than  of  ovaritis.  When  the  cause  of  sterility 
rests  in  the  ovary,  the  explanation  lies  in  the  destruction  of  the  ova 
and  in  the  failure  of  the  follicles  to  rupture  through  the  thickened 
stroma,  tunica  albuginea,  and  surrounding  adhesions. 

When  suppuration  of  an  ovary  follows  upon  ovaritis  the  symptoms 
are  all  aggravated.  In  acute  abscess  of  the  ovary  the  symptoms  are 
all  masked  by  the  complicating  peritonitis,  metritis,  and  salpingitis. 

Increase  in  the  pulse-rate  and  ele^"ation  of  temperature  are  to  be 
expected  in  acute  abscesses,  but  are  often  wanting  in  the  chronic  stage. 

In  determining  the  cause  of  the  infection  it  is  important  to  consider 
the  clinical  history,  as  a  possible  childbirth,  abortion,  or  gonorrheal 
infection  may  play  a  part. 

Physical  examination  of  the  pelvic  viscera  and  of  the  leucorrheal 
discharge  may  reveal  a  gonorrheal  or  tuberculous  infection  of  other 
portions  of  the  genital  tract. 


PLATE    XXIV 


?^: 


Tuboovarian  Abscess.     (Watkins.) 

Exact  size.     The  tube  curves  over  the  tumor  and   is  seven 
inches   long. 


INFLAMMATION  OF   THE  OV ABY  491 

The  diagnosis  is  made  in  part  })y  a  consideration  of  the  above  symp- 
toms, but  an  absohite  diagnosis  cannot  be  made  without  a  physical 
examination,  and  is  often  reserved  until  an  exploratory  incision  offers 
further  light. 

Tenderness  and  pain  may  be  complained  of  in  the  presence  of  a 
perfectly  normal  ovary,  and  chronic  ovaritis  may  exist  without  causing 
pain  or  tenderness  on  pressure. 

Direct  palpation  of  the  ovary  in  a  bimanual  examination  under 
anesthesia  is  indispensable  in  making  a  diagnosis.  The  slight  increase 
in  size  and  consistency  of  the  diseased  ovary,  together  with  evidence 
of  infection  elsewhere  in  the  genital  tract,  will  best  suggest  the  diagnosis. 

The  diagnosis  cannot  be  based  upon  the  increase  in  size  in  the  absence 
of  pain  and  tenderness.  Hypertrophy  and  cystic  degeneration  of  the 
ovary  will  cause  a  similar  increase  in  the  size. 

Abscess  of  the  ovary  cannot  be  diagnosticated  from  constitutional 
symptoms.  ChiUs,  fever,  rapid  pulse,  and  pain  may  all  be  absent 
in  the  presence  of  an  ovarian  abscess. 

The  diagnosis  is  based  upon  the  jSnding  of  a  rounded  swelling  beside 
or  behind  the  uterus,  and  not  immediately  connected  with  it.  The 
tube  may  be  traced  from  the  swelling  to  the  horn  of  the  uterus.  The 
ovary  is  tender  to  pressure,  and  is  always  restricted  in  its  movements 
by  adhesions.    Fluctuation  is  not  often  elicited. 

It  is  sometimes  possible  to  judge  of  the  liability  of  the  abscess  to 
rupture  by  the  degree  of  tension  associated  with  the  pain.  At  such 
a  time  the  temperature  and  pulse  are  usually  elevated,  and  there  are 
increasing  pressure  symptoms  referred  to  the  rectum  and  bladder, 
and  along  the  sacral  nerves  to  the  thighs  and  back. 

On  rupture  of  the  abscess  the  temperature  may  fall  and  the  pain 
cease.  If  the  abscess  has  ruptured  through  the  vagina,  rectum,  bladder, 
or  abdominal  wall,  there  will  be  an  escape  of  pus,  which  is  usually  fetid 
and  mixed  with  blood.  If  the  abscess  ruptures  into  the  peritoneal 
cavity  and  the  pus  is  confined  by  adhesions,  there  will  be  a  moderation 
in  the  temperature  and  pain.  If  no  adhesions  protect  the  peritoneum, 
symptoms  of  general  supj^urative  peritonitis  will  rapidly  follow.  Return 
of  the  abscess  in  the  ovary  is  of  common  occurrence.  Fistulse  and 
chronic  suppuration  are  possible  results  which  sometimes  demand  the 
removal  of  the  sac  long  after  a  spontaneous  rupture. 

Differential  Diagnosis. — Congestion  of  the  ovary  may  be  mistaken  for 
an  inflammation.  The  history  of  the  development  of  the  lesion  and  the 
duration  and  intensity  of  the  disturbance  are  the  guides  to  a  diagnosis. 
Xo  sharp  line  can  be  drawn  between  these  lesions,  even  by  anatomical 
studies  of  removed  ovaries,  and  hence  it  is  impossible  to  clearly  define 
the  two  conditions. 

Salpingitis  is  often  associated  with  ovaritis,  and  the  two  may  be 
inseparably  connected,  so  that  it  is  impossible  to  distinguish  the  ovary 
from  the  tube  in  a  bimanual  examination.  Adhesions  binding  the 
tube  and  ovary  may  unite  them  into  a  single  rounded  or  oblong  tumor 
mass. 


492  FALLOPIAN  TUBES  AND  OVARIES 

In  general  it  may  be  said  that  inflammatory  swellings  of  the  tube 
are  elongated,  retort-shaped,  and  immediately  connected  with  the  horn 
of-  the  uterus,  while  inflammatory  swellings  of  the  ovary  are  round  and 
not  so  intimately  connected  with  the  uterus. 

Parametric  exudates  lie  at  a  lower  level  in  the  pelvis  than  does  an 
ovarian  abscess.  The  swelling  is  more  dift'use  and  is  absolutely  immov- 
able. Furthermore,  a  parametric  exudate  is  intimately  connected  with 
the  uterus,  and  is  more  often  unilateral  than  are  ovarian  abscesses. 
An  ovarian  abscess  is  slower  in  its  development  and  absorption  than 
is  a  parametric  exudate. 

Perityphlitis  is  usually  not  difficult  to  distinguish  from  inflammatory 
lesions  of  the  ovary.  The  higher  location  on  the  right  side  and  the 
accompanying  disturbances  of  the  digestive  organs  will  usually  serve 
to  exclude  the  ovary.  The  diagnosis  will  be  made  with  certainty  by 
outlining  the  ovary  apart  from  the  perityphlitic  exudate. 

Newgrowths  of  the  ovary,  including  ovarian  cysts,  are  less  tender  to 
pressure,  the  pain  is  rarely  so  fixed,  and  the  outline  of  the  tumor  is 
often  quite  irregular.  Finally,  their  tendency  to  grow  to  a  large  size 
will  serve  as  points  of  distinction. 

The  echinococcus  has  been  identified  in  the  ovary  by  Freund,  Schultze, 
Schatz,  Orth,  and  Pfannenstiel.  The  diagnosis  can  only  be  made  by 
the  discovery  of  the  organism  in  the  ovary. 

Treatment. — The  conservative  management  of  ovaritis  in  the  acute 
and  chronic  stages  does  not  differ  essentially  from  that  of  salpingitis. 
For  the  non-operative  methods  of  treatment  the  reader  is  referred  to 
page  467. 


CHAPTER  XXI 
PERITONITIS 


General  Peritonitis 

Non-septic,  Traumatic 
Septic 


Puerperal 

Gonorrheal 

Tuberculous 


Postoperative  1  Pelvic  Peritonitis 

GENERAL  PERITONITIS 

There  are  two  distinct  forms  of  peritonitis,  the  non-septic  or 
traumatic,  the  result  of  injury  to  the  peritoneum,  and  the  septic,  in 
which  infectious  microorganisms  are  the  essential  factors.  In  addition 
to  these  two  chief  varieties  we  will  refer,  under  separate  headings,  to 
tuberculous  and  cancerous  forms. 

Non-septic  or  Traumatic  Peritonitis. — Xon-septic  or  traumatic  peri- 
tonitis may  be  said  to  develop  to  a  greater  or  lesser  degree  in  every 
abdominal  section  in  which  the  peritoneum  is  exposed.  It  is  particularly 
marked  when  the  peritoneum  is  stripped  from  adherent  inflammatory 
growths  or  new-formations. 

In  retroflexion  of  the  uterus,  in  prolapsed  ovaries,  and  in  pelvic  and 
abdominal  tumors  there  are  not  infrequently  encountered  adhesions 
which  are  the  result  of  mechanical  irritation  of  the  peritoneum. 

Postoperative  adhesions,  binding  peritoneal  surfaces  together,  are 
the  result  of  exposure  of  the  peritoneum  to  the  drying  influences  of 
the  air,  and  of  rough  handling  by  the  operator. 

Clinical  Manifestations. — Marked  clinical  symptoms  can  only  develop 
when  extensive  surfaces  are  involved-  When  extensive  peritoneal 
surfaces  are  denuded  of  their  endothelial  covering  in  the  process  of 
an  operation,  the  patient  will  usually  complain  of  some  local  tenderness 
and  pain,  of  a  slight  rise  in  temperature,  and  possibly  of  some  degree 
of  constipation.  When  the  area  involved  is  great  there  may  be  all 
the  clinical  evidences  of  general  peritonitis.  The  tympany,  rigidity 
of  the  abdominal  muscles,  pain,  tenderness,  constipation,  nausea, 
vomiting,  and  rise  of  temperature  and  pulse-rate,  all  suggest  a  general 
involvement  of  the  peritoneum. 

Prognosis. — The  prognosis  is  good  unless  ileus  should  develop. 
Extensive  adhesions  are  known  to  absorb,  but,  as  a  rule,  they  persist 
and  continue  to  give  rise  to  local  pain  and  tenderness  and  to  disturbed 
functions  of  the  involved  organs. 

Treatment. — Prophylaxis  is  of  prime  importance.  In  all  abdominal 
operations  the  utmost  care  should  be  exercised  to  prevent  undue 
exposure  of  the  peritoneum,  both  to  the  air  and  to  handling.     To 


494  .  PERITONITIS 

accomplish  this  the  intestines  should  be  carefully  walled  off  from  the 
field  of  operation  by  gauze  packs  Avrung  out  in  hot  sterile  normal 
salt  solution. 

All  raw  surfaces  should  be  carefully  covered  with  peritoneum,  but 
when  this  is  impossible,  subsequent  adhesions  may  be  prevented  by 
lightly  charring  the  denuded  surface  with  the  actual  Paquelin  cautery 
at  a  dull  glow. 

In  this  connection  the  author  favors  the  practice  of  Dr.  Frank 
Simpson,  of  Pittsburg,  who  applies  an  ice-bag  to  the  abdomen  as  a 
preventive  measure.  Gellhorn  extols  the  application  of  dry  heat  to 
the  abdomen  as  a  preventive  measure  to  the  formation  of  adhesions. 
(See  page  210.) 

Septic  Peritonitis. — Contrary  to  the  previously  accepted  views  the 
peritoneum  is  not  readily  infected  as  compared  with  other  tissues; 
this  fact  is  well  established  both  clinically  and  experimentally. 

Infectious  microorganisms  are  the  essential  factors  in  the  develop- 
ment of  septic  peritonitis,  but  many  predisposing  factors  are  operati\'e 
in  rendering  the  peritoneum  susceptible  to  infection. 

Predisposing  Causes. — Whatever  lowers  the  resistance  of  the  peri- 
toneum will  render  it  more  liable  to  infection;  in  this  category  should 
be  placed  the  long  exposure  of  peritoneal  surfaces  to  the  air,  rough 
handling,  and  the  breaking  up  of  adhesions. 

Again,  the  general  lowered  resistance  of  the  individual  may  be 
regarded  as  a  predisposing  factor.  Kelly  says:  "The  pathological 
and  bacteriological  stud>'  of  all  the  cases  of  peritonitis  which  have 
come  to  autopsy  in  the  Johns  Hopkins  Hospital  has  clearly  demon- 
strated the  greater  liability  to  the  invasion  of  bacteria  on  the  part  of 
persons  subject  to  chronic  diseases  of  one  or  several  of  the  important 
viscera." 

The  leaving  of  foreign  bodies  in  the  abdominal  cavity,  such  as  sponges 
and  instruments,  is  sometimes  responsible  for  the  development  of  septic 
peritonitis.  Other  foreign  bodies  may  produce  a  generalized  or  local- 
ized septic  peritonitis,  i.  e.,  wandering  fibroids,  the  escaped  fetus  in  a 
ruptured  ectopic  pregnancy,  the  escaped  fluid  from  a  ruptured  cyst  or 
Fallopian  tube,  and  the  accumulation  of  blood  following  a  pelvic  or 
abdominal  operation. 

Essential  Causes. — Referring  to  the  essential  causes  of  septic  peri- 
tonitis, we  have  to  consider  the  source  of  the  invading  microorganisms, 
their  number,  and  above  all  their  virulence. 

We  have  frequently  observed  pus  escape  into  the  free  abdominal 
cavity  without  producing  peritonitis;  such  pus  is  sterile,  or  at  most  the 
contained  microorganisms  are  of  low  virulence. 

Furthermore,  there  is  wide  variation  in  the  absorbing  ppwer  of 
the  various  parts  of  the  peritoneum;  the  pelvic  peritoneum  has  a 
relatively  low  power  of  absorption,  and  hence  is  less  susceptible  to 
infection  and  to  the  spread  of  the  infection  to  the  upper  regions  of  the 
abdomen. 

Of  the  ordinary  bacteria  causing  peritonitis,  by  far  the  most  virulent 


GENERAL  PERITONITIS  495 

and  destructive  is  the  streptococcus  pyogenes;  the  resulting  inflam- 
matory involvement  is  rarely  circumscribed,  but  spreads  rapidly  to 
adjacent  and  remote  parts  of  the  peritoneum. 

The  staphylococcus  aureus  usually  has  a  lower  degree  of  virulence, 
and  the  resulting  inflammatory  reaction  is  commonly  localized;  and 
when  involving  all  or  the  greater  part  of  the  peritoneum,  the  prognosis 
is  not  so  grave  as  in  a  streptococcic  infection. 

Other  microorganisms  which  invade  the  peritoneum  and  cause 
a  general  inflammatory  reaction  are  the  gonococcus,  colon  bacillus, 
tubercle  bacillus,  bacillus  proteus,  bacillus  pyocyaneous,  bacillus 
typhosus,  and  micrococcus  lanceolatus. 

Anatomy. — The  inflammatory  reaction  in  the  peritoneum  is  not 
always  proportionate  to  the  degree  of  general  intoxication.  Indeed, 
the  most  virulent  infections  may  result  fatally  before  there  is  time 
for  an  inflammatory  reaction  to  develop  in  the  peritoneum,  beyond 
that  of  a  moderate  congestion  and  a  limited  amount  of  serofibrinous 
exudate.  The  greater  the  virulence,  the  less  the  exudate.  In  such 
cases  a  microscopic  examination  of  the  peritoneum  will  generally 
reveal  innumerable  streptococci. 

The  pathological  findings  in  acute  peritonitis  depend  upon  the 
nature  and  intensity  of  the  infection.  There  may  be  no  more  than  a 
loss  of  luster  and  a  slight  deposit  of  fibrin  upon  the  peritoneum  when 
the  infecting  microorganisms  are  of  low  virulence.  In  the  development 
of  an  acute  inflammation  of  the  peritoneum  there  is  first  a  reddening 
of  the  bowel,  followed  by  a  loss  of  luster  and  agglutination  of  the  coils 
of  bowel  by  a  deposit  of  yellowish-white  fibrin  flakes.  Peritoneal 
fluid  usually  accumulates  early  in  the  process.  This  fluid  is  turbid^ 
and  contains  soft  pultaceous  masses  and  flakes.  Soon  the  fluid 
becomes  purulent.  Later  in  the  process  this  exudate  becomes  encapsu- 
lated between  coils  of  bowel,  and  is  thick  and  creamy.  The  fibrinous 
exudate  becomes  firmly  organized  into  adhesions. 

The  chronic  stage  may  develop  insidiously  or  may  be  the  terminal 
stage  of  an  acute  inflammation.  Chronic  peritonitis  may  be  divided 
into  (1)  chronic  exudative  peritonitis,  in  which  there  is  a  serous,  sero- 
fibrinous, or  fibrinopurulent  exudate,  with  more  or  less  of  a  plastic 
exudate;  (2)  chronic  exudative  and  adhesive  peritonitis,  in  which  there 
is  a  preponderance  of  plastic  exudate  leading  to  the  formation  of 
adhesions;  (3)  chronic  hyperplastic  peritonitis,  with  the  formation  of 
plaques  or  sheets  of  hyaline  material  of  a  whitish,  cartilaginous  char- 
acter, together  with  a  fibrinous  exudate. 

Clinical  Manifestations. — It  is  not  easy  to  recognize  a  general  peri- 
tonitis in  its  early  stage,  at  a  time  when  there  is  the  greatest  prospect 
of  cure. 

hi  'postoyerathe  seytic  peritcmitis  the  facial  expression  of  the  patient 
is  suggestive.  She  appears  anxious  and  careworn,  and  as  the  end 
approaches,  cyanosis  develops  and  the  extremities  become  cold  and 
clammy.  Little  dependence  can  be  placed  upon  the  temperature. 
There  is  usually  some  elevation  of  temperature  in  the  beginning,  but 


496  PERITONITIS 

later  it  may  be  normal  or  subnormal.  The  pulse  is  a  reliable  guide  and  a 
good  indication  of  the  progress  of  the  disease.  It  is  increasingly  rapid, 
becoming  weaker  and  more  rapid  as  the  disease  advances.  The  patient 
lies  with  both  legs  flexed.  Vomiting  and  hiccough  become  more  and 
more  persistent.  The  vomitus  is  not  great,  and  is  usually  black  from 
the  presence  of  digested  blood.  Abdominal  pain  is  at  first  intense,  but 
as  the  end  approaches  and  the  patient  becomes  profoundly  toxic,  the 
pain  recedes  and  the  patient  may  express  herself  as  being  quite  com- 
fortable; this  is  an  unfavorable  sign.  All  the  secretions  are  scanty. 
The  skin  is  dry  until  near  the  end,  when  it  is  covered  with  cold  sweat, 
and  the  tongue  is  dry  and  coated.  The  abdominal  distention  and 
muscular  rigidity  increase,  and,  as  a  rule,  the  bowels  fail  to  move, 
though  diarrhea  is  an  occasional  accompaniment. 

Prognosis. — The  outlook  is  always  grave  in  septic  peritonitis,  but 
modern  methods  of  treatment  have  done  much  to  reduce  the  mortality. 

The  pulse  is  a  better  guide  to  the  prognosis  than  the  temperature. 
The  number  of  leucocytes  in  the  blood  is  likewise  of  prognostic  value 
when  correctly  interpreted;  an  increasing  leucocytosis  in  the  course 
of  a  septic  peritonitis  indicates  increasing  tissue  resistance  on  the 
part  of  the  patient,  and  hence  the  value  of  making  repeated  blood- 
counts  during  the  course  of  the  disease. 

When  terminating  fatally  the  course  will  usually  be  run  in  from 
three  to  five  days,  but  death  may  ensue  within  twenty-four  hours,  or 
as  late  as  the  fourteenth  day. 

Treatment  of  General  Septic  Peritonitis. — In  the  early  years  of  modern 
surgery  the  choice  was  always  in  favor  of  extraperitoneal  operations  as 
opposed  to  intraperitoneal  procedures  in  view  of  the  great  liability 
of  infection  of  the  peritoneum;  but  of  late  years  surgical  technic  has 
become  so  perfected  that  the  paramount  question  is,  How  can  the  best 
results  be  obtained  irrespective  of  the  chances  of  infection  ? 

Prophylaxis.— The  utmost  confidence  is  imposed  in  our  methods  of 
safeguarding  the  peritoneum  from  invasion  by  septic  germs.  One 
of  the  most  important  considerations  in  the  prevention  of  general  septic 
peritonitis  is  involved  in  the  management  of  cases  of  acute  pelvic 
infection.  The  abdomen  should  never  he  opened  in  the  presence  of  a 
circumscribed,  acute  pelvic  inflammation,  and  all  recent  accumulations 
of  pus  in  the  pelvis  should  be  drained  through  the  vagina.  The  question 
as  to  how  soon  after  an  acute  attack  of  pelvic  infection  it  is  safe  to  enter 
the  abdominal  cavity  for  the  removal  of  offending  organs  is  difficult 
to  answer.  The  acute  pain  and  tenderness,  the  temperature  and  rise 
of  pulse-rate,  and  the  leucocytosis  must  not  only  have  passed  away, 
but  some  time  should  intervene  in  order  that  the  microorganisms  may 
lose  their  virulence  for  want  of  an  environment  favorable  ,to  their 
growth  and  activity.  It  is  the  author's  practice  to  postpone  all  surgical 
interference  by  way  of  the  abdomen  for  a  period  of  not  less  than  three 
months,  and  in  the  meantime  to  endeavor  to  allay  the  inflammatory 
reaction  by  rest,  hot  vaginal  douches,  and  glycerin  and  ichthyol 
tampons.     (See  Chapters  X  and  XL) 


GENERAL  PERITONITIS  497 

If  the  operator  should  be  misled  into  the  abdominal  cavity  by  the 
lack  of  local  evidence  of  an  acute  pelvic  inflammation,  and  the  want 
of  a  reliable  history,  and  upon  inspection  of  the  pelvic  contents  through 
the  abdominal  incision  he  is  confronted  with  the  presence  of  an  acute 
inflammatory  reaction  in  the  tissues  lying  outside  the  uterus,  it  would 
be  a  commendable  procedure  for  him  to  close  the  abdominal  incision 
without  further  interference.  This  should  be  done  not  only  to  protect 
the  peritoneal  cavity  from  possible  contamination,  but  also  to  con- 
serve tissues  which  might  be  saved  by  tentative  measures.  Not  infre- 
quently the  surgeon  will  find  that  there  will  be  no  occasion  for  opening 
the  abdomen  at  a  later  date  because  of  the  relief  from  all  disturbing 
symptoms  and  the  apparent  restoration  of  the  tissues  to  the  normal 
by  the  employment  of  conservative  measures. 

If  in  an  abdominal  operation  the  gloves  of  the  operator  or  assistants 
become  soiled  by  infected  material  or  are  torn,  they  should  be  imme- 
diately changed,  and  all  soiled  sponges,  pads,  and  towels  should  also 
be  discarded. 

Careful  hemostasis  and  the  covering  of  all  raw  surfaces  with  perito- 
neum are  important  factors  in  the  prevention  of  abdominal  infections. 

Rough  handling  and  unnecessary  prolonged  exposure  of  the  perito- 
neum predispose  to  peritonitis  by  lowering  the  resistance  of  the  tissues 
and  by  affording  greater  opportunity  for  the  invasion  of  microorganisms. 

No  peritoneal  surface  should  be  left  exposed  in  an  operation  for  a 
longer  time  than  is  absolutely  required  for  the  carrying  out  of  the 
operation;  gauze  pads  should  be  used  liberally  in  the  covering  of  all 
intra-abdominal  organs  which  are  not  under  immediate  inspection. 

Much  can  be  done  in  the  way  of  preventing  the  upward  spread  of 
a  pelvic  inflammation  by  placing  the  patient  in  the  Fowler  position. 
This  should  be  done  during  the  course  of  an  acute  pelvic  inflammatory 
attack  both  before  and  after  operation,  and  in  all  cases  of  acute  or 
chronic  pelvic  inflammation  operated  through  the  vagina  or  abdomen. 

Active  Treatment. — Knott^  reported  19  cases  of  general  septic  peri- 
tonitis with  17  recoveries;  4  of  this  number  were  gynecological  cases. 
Knott  makes  a  liberal  incision  in  the  median  line.  A  long  drainage- 
tube  is  inserted  through  the  lower  end  of  the  abdominal  incision  and 
is  carried  to  the  floor  of  the  pelvis.  Vaginal  counter-drainage  is  made 
through  the  cul-de-sac,  using  a  rubber  tube.  The  whole  abdominal 
cavity  is  washed  out  with  gallons  of  sterile  normal  salt  solution.  The 
abdominal  incision  is  closed  with  stitches  close  to  the  drainage-tube 
and  quantities  of  sterile  dressings  are  applied.  The  patient  is  then 
elevated  to  a  sitting  posture,  being  supported  from  behind  by  pillows. 
The  head  of  the  bed  is  elevated  twenty-four  to  thirty  inches  from  the 
floor.     The  dressings  should  be  changed  frequently. 

The  question  of  confining  the  bowels  with  opiates  as  opposed  to  free 
catharsis  is  still  somewhat  under  discussion.  The  author  is  in  accord 
with  the  general  practice  of  opening  the  bowels  at  the  earliest  possible 

1  Annals  of  Surgery,  July,  1905. 
32 


498  PERITONITIS 

moment,  and  of  keeping  them  open,  if  possible,  thronghout  the  entire 
course  of  the  infection.  To  accompHsh  this,  I  grain  of  calomel  may 
be  given  every  hour,  together  with  a  dram  of  Epsom  salts,  followed 
by  enemata  consisting  of  Epsom  salts,  2  ounces;  glycerin,  2  ounces; 
sweet  oil,  4  ounces.  When  there  is  much  gas  a  few  drops  of  turpentine 
may  be  added. 

An  effective  enema  is  a  pint  each  of  warm  molasses  and  milk;  it  has 
a  soothing  effect,  and  often  accomplishes  the  expulsion  of  gas  and  the 
unloading  of  the  bowel  of  fecal  matter  when  other  means  fail. 

The  author  has  also  found  satisfaction  in  the  injection  into  the  bowel 
of  a  pint  of  normal  salt  solution  with  2  ounces  of  alum. 

Persistent  vomiting  may  preclude  the  administration  of  cathartics 
by  the  mouth,  and  if  so,  the  only  resort  is  rectal  injections,  preceded 
by  a  hypodermic  injection  of  j  g-  grain  of  physostigmin. 

All  efforts  to  move  the  bowels  may  fail,  and  death  ensue  within 
five  days  of  the  onset  of  the  peritonitis. 

When  the  pain  cannot  be  controlled  by  the  application  of  heat  or 
cold  to  the  abdomen,  hypodermic  injections  of  morphine  must  be 
resorted  to,  but  these  must  be  used  sparingly. 

No  antipyretics,  other  than  cold  sponging,  should  be  used  because 
o'f  their  depressing  effects. 

The  strength  of  the  patient  should  be  maintained  by  nutrient  enemata 
if  the  stomach  will  not  retain  food.  When  neither  the  bow^el  nor  stomach 
will  retain  nourishment,  the  outlook  is  exceedingly  grave. 

Nourishment  by  the  mouth  is  withheld  until  vomiting  has  ceased. 

Stimulation  may  be  resorted  to  by  hypodermoclysis  of  normal  salt 
solution,  also  by  the  hypodermic  injection  of  strychnine,  gr.  g-^Q-  to  -gV, 
every  tw^o  to  six  hours,  and  whisky,  in  1  to  4  dram  doses,  given  by 
mouth,  bowel,  or  hypodermically. 

Operative  Treatment. — There  is  no  more  difficult  problem  to  solve 
than  the  question  of  when  to  interfere  surgically  in  the  course  of  septic 
peritonitis.  The  most  favorable  time  for  surgical  intervention  is  at 
the  very  onset  of  the  peritonitis,  but  the  difficulty  arises  in  the  making 
of  the  diagnosis  of  peritonitis  in  its  initial  stage  before  it  has  involved 
any  considerable  portion  of  the  peritoneum.  So  many  conditions,  such 
as  gas  distention,  ileus,  hemorrhage,  and  auto-intoxication,  having  no 
relation  to  peritonitis,  may  closely  simulate  peritonitis  in  its  early 
stages,  and  hence  one  naturally  hesitates  to  interfere  surgically  until 
the  clinical  evidences  are  well-marked.  Furthermore,  the  case  may  be 
seen  at  a  time  when  it  is  believed  that  any  operative  procedure  will 
hasten  the  fatal  issue,  yet  such  cases  are  occasionally  saved  by  free 
drainage;  hence,  the  surgeon  can  never  be  assured  as  to  the  proper 
procedure.  The  result  is  that  he  is  impelled  to  take  the  chance  of 
operating,  though  the  chance  may  be  ever  so  small. 

General  septic  peritonitis  has  at  times  been  known  to  recover  without 
surgical  intervention,  but  the  event  should  never  be  anticipated. 

x\ll  this  confirms  the  statement  that  there  is  no  more  difficult  problem 
in  surgery  than  that  involved  in  the  surgical  treatment  of  septic  peri- 


GENERAL  PERITONITIS  499- 

tonitis,  both  in  its  early  and  late  stages.  The  late  achievements  in 
the  treatment  of  septic  peritonitis  have  brought  us  to  the  conclusion 
that  in  all  cases,  save  those  that  are  in  a  moribund  state,  the  abdomen 
should  be  opened  and  freely  drained;  and  in  all  cases  when  there  is 
good  reason  to  believe  that  peritonitis  is  beginning  and  is  advancing, 
and  in  which  conservative  measures  have  been  tried  without  avail,  an 
exploratory  incision  should  be  made.  The  fact  that  many  of  the  condi- 
tions which  are  confused  with  peritonitis  justify  an  exploratory  incision 
into  the  abdomen,  gives  added  justification  to  surgical  intervention  in 
suspected  cases. 

After  it  has  been  determined  to  establish  drainage  the  question 
arises.  Shall  the  drainage  be  vaginal  or  abdominal? 

It  may  be  said  that  vaginal  drainage  offers  the  least  risk,  but  it  is 
an  uncertain  procedure  because  one  can  never  be  certain  of  thorough 
drainage.  Whenever  localized  accumulations  of  pus  are  found  in  the 
pelvis  they  should  be  drained  through  the  vagina.  Having  succeeded 
in  establishing  free  drainage  through  the  vagina,  if  improvement  does 
not  ensue,  but,  on  the  contrary,  the  evidences  of  general  peritonitis 
progress,  the  abdomen  must  be  opened  for  counter-drainage. 

When  no  accumulation  of  pus  is  found  in  the  pelvis,  vaginal  drainage 
alone  is  not  indicated,  and  can  only  be  considered  as  a  secondary  pro- 
cedure to  abdominal  drainage. 

When  draining  for  postoperative  peritonitis,  the  stitches  in  the 
lower  portion  of  the  wound  should  be  removed  and  the  gloved  finger 
carefully  inserted  in  the  direction  of  the  uterus  and  broad  ligaments, 
in  search  of  pockets  of  pus.  The  search  is  continued  to  the  extent  of 
satisfying  one's  self  that  all  pockets  of  pus  have  been  opened  and  free 
drainage  established  through  the  opening  in  the  abdominal  wall.  In 
the  search  for  the  accumulated  pus  it  may  be  necessary  to  explore  the 
greater  part  of  the  abdominal  cavity.  Caution  must  be  exercised  in  so 
doing  for  fear  of  contaminating  portions  of  the  peritoneum  not  involved 
in  the  infection;  hence,  the  search  should  only  extend  to  those  portions 
of  the  peritoneum  that  are  visibly  involved. 

The  drainage  should  be  free  and  lead  to  the  most  dependent  portions 
of  the  infected  zone.  For  this  purpose  the  author  uses  one  or  more 
fenestrated  rubber  tubes,  one-half  inch  in  diameter.  Two,  three,  or 
possibly  four  such  tubes  should  be  placed,  one  for  each  of  the  pus 
cavities  found,  and  all  are  brought  through  the  abdominal  incision. 
If  thought  advisable,  a  second  and  even  a  third  incision  may  be  made 
through  the  abdominal  wall  in  order  to  establish  more  efficient  drainage. 

When  possible,  drainage  should  be  established  through  the  vagina 
by  making  a  transverse  incision  an  inch  in  length  through  the  posterior 
fornix.  A  gauze  pack  or  rubber  tube  is  passed  from  above  through  the 
incision  into  the  vagina. 

The  greatest  caution  should  be  exercised  in  the  application  of  sponges 
and  swabs  for  fear  of  removing  the  protecting  lymph  and  endothelium 
from  the  peritoneal  surfaces.  The  same  objection  is  open  to  irrigation 
of  the   abdominal   cavity,  which  presents  the   additional  danger  of 


500  PERITONITIS 

spreading  the  infection  throughout  the  peritoneal  surface  not  as  yet 
involved.  For  the  above  reason  the  author  dispenses  with  both  swabs 
and  irrigation,  and  establishes  free  drainage  only. 

After  the  drainage-tubes  are  in  place  the  wound  is  dressed  with  an 
abundance  of  sterile  gauze  and  the  patient  placed  in  bed  in  the  Fowler 
position. 

A  rectal  tube  is  inserted  high  in  the  bowel,  and  through  this  normal 
salt  solution  is  slowly  injected  at  the  rate  of  15  drops  per  njinute,  and 
continued  for  twenty-four  or  more  hours. 

Puerperal  Peritonitis. — Acute  diffuse  puerperal  peritonitis  is  generally 
regarded  as  fatal  unless  operated.  When  the  infection  has  invaded 
the  blood-stream,  drainage  of  the  abdomen  will  be  of  no  avail.  If  the 
blood  is  sterile,  no  time  should  be  lost  in  establishing  free  drainage. 
Fortunately  the  blood  is  late  in  being  invaded  in  these  cases. 

Treatment. — The  treatment  of  acute  diffuse  puerperal  peritonitis  is 
most  discouraging;  this  is  in  marked  contrast  to  that  of  general  peri- 
tonitis following  appendicitis.  In  diffuse  puerperal  peritonitis  there 
are  microorganisms  of  high  virulence  and  the  resistance  of  the  indi- 
vidual is  commonly  low";  whereas  in  peritonitis  following  appendicitis 
the  micro5rganisms  are  usually  of  lower  virulence,  and  the  resistance 
of  the  individual  is  usually  high.  Then,  too,  there  is  better  oppor- 
tunity to  establish  direct  drainage  of  the  primary  focus  of  infection 
in  appendicitis. 

All  will  agree  that  early  and  free  drainage  of  the  peritoneal  cavity 
is  imperative.  Of  this  there  is  no  question,  but  the  difficulty  lies  in 
the  making  of  a  diagnosis  early  enough  to  insure  good  results.  When 
the  infection  has  spread  directly  through  the  uterine  wall  to  the  peri- 
toneum we  encounter  germs  of  high  virulence,  and  drainage  of  the 
abdomen  will  rarely  be  successful.  If,  on  the  other  hand,  the  infection 
invades  the  peritoneum  by  way  of  the  tubes  we  meet  germs  (strepto- 
cocci, staphylococci,  gonococci)  of  lower  virulence;  hence,  the  results 
from  drainage  are  better. 

In  general,  the  technic  of  abdominal  drainage,  of  the  continuous 
administration  of  salt  solution  by  the  bowel,  and  of  the  enforcement 
of  Fowler's  position  does  not  differ  from  that  practised  in  the  manage- 
ment of  peritonitis  following  appendicitis,  and  will  not  be  discussed 
here  in  detail.  It  is,  however,  of  great  importance  to  consider  the 
question  of  removing  the  primary  focus  of  infection. 

If  an  infected  uterus  has  been  perforated  or  lacerated  it  should  be 
removed,  provided  the  condition  of  the  patient  will  permit.  If  it  is 
evident  that  the  patient  cannot  withstand  so  formidable  an  operation, 
a  dam  of  gauze  should  be  placed  about  the  uterus  to  protect  the 
general  peritoneal  cavity.  When  the  infection  has  spread  to  the  tubes 
their  removal  is  advised  if  the  condition  of  the  patient  will  warrant. 
A  ruptured  pus-tube  should  be  removed.  There  is  some  difference  of 
opinion  as  to  the  advisability  of  flushing  the  abdominal  cavity  with 
salt  solution,  but  the  consensus  of  opinion  is  strongly  opposed  to  the 
practice.     When  there  is  great  distention  of  the  bowel  that  cannot  be 


GENERAL  PERITONITIS  501 

relieved  by  drainage  of  the  peritoneal  cavity,  and  by  the  usual  means 
employed  for  the  expulsion  of  gas,  multiple  punctures  of  the  bowel  may 
be  made. 

Fromme  reported  12  cases  operated  on  for  acute  diffuse  puerperal 
peritonitis;  6  of  this  number  were  lymphatic  invasions;  all  died.  Only 
2  of  the  12  cases  recovered.  These  experiences  do  not  condemn  the 
practice  of  draining  the  abdominal  cavity,  but  serve  to  emphasize  the 
necessity  of  an  early  diagnosis. 

We  have  a  suggestion  in  the  practice  of  Latzki,  who  makes  an  explor- 
atory abdominal  incision  early  in  suspected  cases  of  peritonitis.  Henkel 
advises  an  early  exploration  through  the  cul-de-sac  and  the  taking  of 
cultures  from  the  peritoneum. 

The  prognosis  depends  much  upon  the  nature  of  the  infecting 
organism.  If  there  is  a  gonococcus  or  a  mixed  colon  infection  the 
prognosis  is  relatively  good;  if  there  is  a  streptococcic  infection  the 
prognosis  is  bad. 

Bumm  drained  45  cases,  with  recovery  in  48  per  cent.;  Wormser, 
177  cases,  with  recovery  in  37  per  cent.  Latzki  operated  47  cases 
of  puerperal  peritonitis  out  of  a  total  of  12-5.  Of  the  51  cases  not 
subjected  to  operation  only  two  recovered;  of  the  47  operated  on,  17 
(24  per  cent.)  recovered.  He  observes  that  none  of  the  cases  with 
great  distention  of  the  bowel  recovered.  If  there  is  great  distention 
of  the  bowel,  which  is  not  readily  controlled  by  eserine,  multiple 
punctures  should  be  made  into  the  bowel. 

In  the  fulminating  forms  of  peritonitis  no  good  can  ensue  from 
surgical  interference.  In  the  less  virulent  forms  early  drainage  is  imper- 
ative. This  demands  an  early  diagnosis,  and  suggests  the  advisability 
of  making  exploratory  punctures  and  incisions. 

Gonorrheal  Peritonitis. — Contrary  to  the  views  previously  entertained, 
the  gonococcus  may  invade  the  peritoneum  and  give  rise  to  an  inflam- 
matory reaction.  It  is  not  essential,  however,  that  the  gonococcus 
be  resident  in  the  peritoneum,  in  the  presence  of  an  acute  or  chronic 
inflammatory  lesion  of  the  peritoneum  associated  with  a  gonorrheal 
metritis,  salpingitis,  and  ovaritis. 

It  may  be  assumed  that  the  peritoneum  is  involved  in  the  acute  stage 
of  a  gonorrheal  infection  when  the  pelvic  pains  are  sharp  and  excessive. 

It  is  possible  that  an  acute  pelvic  peritonitis  may  resolve  itself  into 
a  normal  state,  but  when  the  appendages  contain  pus  or  when  the 
infection  is  widespread  and  persistent,  adhesions  are  almost  sure  to 
develop.  These  adhesions  are  at  first  frail,  but  may  develop  into 
strong  bands  which  firmly  unite  the  pelvic  viscera  to  surrounding 
structures. 

Accumulations  of  pus  may  be  found  in  the  meshes  of  the  adhesions, 
with   little   danger   of   contaminating  the   general   peritoneal   cavity. 

Diagnosis. — The  severity  of  the  pain  and  tenderness  in  the  pelvis,  the 
frequent  exacerbations,  the  discomfort  occasioned  by  the  movements 
of  the  patient,  the  tendency  to  bloating  at  the  menstrual  periods,  are 
all  suggestions  of  the  presence  of  pelvic  peritonitis. 


502  PERITOXITIS 

On  bimanual  examination  the  restricted  movements  of  the  uterus  and 
its  appendages,  even  to  complete  fixation,  together  with  the  unusual 
amount  of  pain  occasioned  by  the  manipulations  of  these  organs,  are 
highly  suggestive  of  the  presence  of  adhesions.  If  with  these  findings 
the  organs  are  found  displaced,  the  diagnosis  is  more  nearly  confirmed. 
It  may  be  possible  to  feel  adhesions  by  a  bimanual  examination;  how- 
ever, they  commonly  exist  and  are  not  infrequently  extensive  when  it 
is  impossible  to  feel  them,  and  when  the  pelvic  organs  are  but  little 
restricted  in  their  movements.  It  is  never  possible  to  diagnosticate  the 
absence  of  adhesions  without  inspection  or  palpation  through  an  incision. 

General  gonorrheal  peritonitis  is  exceptionally  rare.  Bumm  states 
that  he  has  never  seen  a  case.  In  his  own  experience  the  author  has 
observed  only  one  such  case,  but  in  this  case  his  clinical  and  postmortem 
diagnosis  was  not  confirmed  by  a  bacteriological  examination.  Martin, 
Broese,  Veit,  Leopold,  Penrose,  Menge,  and  Ceppi  have  all  reported 
cases.  The  majority  of  these  cases,  like  that  of  the  author's,  were 
reported  from  clinical  data. 

Treatment. — The  treatment  of  general  gonorrheal  peritonitis  does 
not  differ  from  that  of  other  forms  of  general  peritonitis. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis  is  now  generally 
regarded  as  a  surgical  disease;  this  applies  particularly  to  the  ascitic 
variety,  and  more  especially  to  the  cases  in  which  the  primary  focus 
can  be  removed.  ^Nluch,  however,  can  be  done  by  medicinal  means, 
and  in  selected  cases  only  medicinal  means  need  be  employed  to 
effect  a  cure. 

Cases  may  be  operated,  not  with  the  hope  of  curing  the  disease, 
but  of  removing  causes  of  obstruction  to  the  bowel  and  of  pressure 
upon  nerves  and  bloodvessels. 

Tuberculous  peritonitis  in  women  is  particularly  amenable  to  surgery 
because  of  the  frequency  with  which  the  disease  is  found  to  be  primary 
in  the  Fallopian  tubes.  According  to  Osier,  30  to  40  per  cent,  are 
primary  in  the  Fallopian  tubes. 

\Yhile  it  is  true  that  the  most  favorable  cases  are  those  in  which 
the  lesion  is  confined  to  the  peritoneum  and  the  organs  resident  in  the 
abdomen  which  are  removable,  i.  e.,  Fallopian  tubes  and  appendix,  it 
is  generally  conceded  that  mild  pulmonary  and  lymphatic  tuberculosis 
do  not  offer  a  contra-indication  to  an  abdominal  section.  Such  is  the 
view  of  Pribram,  Yierorett,  Schwartz,  and  Israel. 

The  fibrous  and  ulcerative  forms  of  peritonitis  are  not  favorable  to 
operation,  and  when  a  tuberculous  enteritis  exists,  one  should  be  slow 
to  interfere  surgically. 

Treatment. — Medical. — The  medical  treatment  of  tuberculous  peri- 
tonitis is  that  employed  in  the  management  of  tuberculosis,  of  the 
lungs.  Good  food  and  fresh  air  are  absolutely  essential.  Such'  tonics 
as^cod-liver  oil,  the  hypophosphites,  the  syrup  of  the  iodide  of  iron, 
and  arsenic  have  their  place,  but  do  not  in  the  .least  supersede  fresh  air 
and  an  abundance  of  nourishing  food.  No  medicine  should  be  given 
that  will  disturb  the  stomach  and  interfere  with  the  ingestion  of  food. 


PELVIC  PERITONITIS  503 

.  Tuberculin  has  been  extolled,  but  it  is  not  clear  that  its  value  is 
great  as  a  curative  agent.  Cures  by  the  administration  of  tuberculin 
have  been  reported  by  Gray,  Rumpf,  McCall,  Leser,  Kummel,  and 
Riegel.  von  Ruck  gives  the  most  encouraging  reports,  having  a  record 
of  three  cures  in  four  cases. 

Surgical. — The  surgical  treatment  of  tuberculous  peritonitis  has  gen- 
erally consisted  in  making  a  median  abdominal  incision,  in  removing 
all  fluid  by  means  of  swabs,  and  irrigating  with  sterile  normal  salt 
solution ;  in  severing  any  adhesive  bands  which  may  obstruct  the  bowel, 
and  finally,  in  removing  the  primary  focus  when  possible.  Unless  pus  is 
present  drainage  is  not  ordinarily  employed.  It  is  seldom  that  vaginal 
drainage  is  established. 

It  is  well  to  remember  that  too  much  surgery  in  these  cases  is  hazard- 
ous. Abdominal  surgery  has  taught  us  much  about  the  self-healing  of 
peritoneal  tuberculosis.  Until  these  cases  were  operated  the  disease 
was  regarded  as  uniformly  fatal.  Of  late  years  it  has  been  the  expe- 
rience of  surgeons  that,  in  a  subsequent  abdominal  operation,  a  well- 
marked  case  of  peritoneal  tuberculosis  seen  in  the  first  section  is  found 
partially  or  completelj^  healed  in  the  second.  The  profession  became 
overzealous  in  the  surgical  treatment  of  tuberculosis  of  the  peritoneum 
because  of  the  encouraging  reports  which  came  from  the  many  clinics. 
In  later  years  it  was  found  that  many  of  these  cases  remained  apparently 
well  for  one  or  more  years  and  then  developed  evidences  of  recurrence. 
Because  of  the  great  number  of  such  recurrences  the  tendency  of  late 
years  is  toward  conservatism. 

It  is  now  believed  that  a  cure  cannot  be  pronounced  with  certainty 
until  the  expiration  of  five  years. 

The  combined  statistics  of  28  foreign  and  9  American  operators 
give  a  total  of  1375  cases  of  peritoneal  tuberculosis  on  which  abdominal 
section  was  done.  Of  this  number  1011  cures  are  reported,  or  a  per- 
centage of  75.5.  Inasmuch  as  no  time  limit  is  placed  on  these  cases 
we  are  to  accept  the  report  as  altogether  untrustworthy.  For  further 
discussion  of  the  subject  see  page  544. 

PELVIC  PERITONITIS 

Definition. — Part  or  all  of  the  pelvic  peritoneum  is  involved  in  the 
inflammatory  process.  We  therefore  speak  of  difi^use  and  localized 
pelvic  peritonitis.  When  localized  various  terms  are  employed  to 
designate  the  location  and  extent  of  the  lesion.  We  speak  of  peri- 
metritis when  the  peritoneal  covering  of  the  uterus  is  affected;  of 
perisalpingitis  and  peri-ovaritis  when  the  peritoneal  coverings  of  the 
tube  and  ovary  are  involved. 

Of  greater  clinical  importance  is  the  distinction  between  general 
abdominal  and  pelvic  peritonitis  and  an  isolated,  well-defined,  pelvic 
peritonitis.  A  pelvic  peritonitis  may  be  primary  or  secondary-  to  a 
general  abdominal  peritonitis — a  fact  of  considerable  importance  in  its 
bearing  upon  the  diagnosis  and  treatment. 


504 


PERITONITIS 


The  infection  is  usually  conveyed  through  the  uterus  and  tubes  to 
the    peritoneum    immediately    surrounding    these    organs.      A    direct 


Fig.  345 


\  M.  Levator  ani.' 

Three  divisions  of  the  pelvic  cavity,  namely,  peritoneal,  subperitoneal,  and  subcutaneous.     (Fehling.) 


Fig.  346 


Sagittal  section  of  the  uterus  to  show  the  manner  in  which  the  peritoneum  is  attached.  .4,  body 
of  the  uterus;  A',  anterior  surface;  A",  posterior  surface;  B,  neck;  C,  isthmus;  1,  cavity  of  the  body; 
2,  OS  internum;  3,  os  externum;  4,  posterior  fornix;  5,  anterior  lip  of  cervix;  6,  anterior  vaginal  wall, 
7,  posterior  vaginal  wall;  8,  vesico-uterine  septum;  9,  wall  of  the  bladder;  10,  peritoneum;  11,  vesico- 
uterine pouch;  12,  cul-de-sac  of  Douglas.     (Testut.) 


PELVIC  PERITONITIS  505 

invasion  from  the  uterus,  tubes,  rectum,  appendix  vermiformis,  or 
bladder  occurs  with  less  frequency. 

It  is  possible  for  infection  to  be  conveyed  along  the  mucosa  of  the 
uterus  and  tubes  to  the  peritoneum  without  causing  anatomical  changes 
in  the  uterus  and  tubes,  or  such  changes  may  be  limited  to  portions  of 
the  mucosa. 

Likewise,  the  lymphatic  channels  may  be  mere  carriers  of  infection 
without  themselves  being  involved.  We  are,  therefore,  not  justified 
in  concluding  that  infection  has  not  passed  by  a  given  route  because 
there  are  no  anatomical  evidences  of  such  an  event. 

Etiology. — All  that  has  been  said  of  the  etiology  of  endometritis 
will  apply  to  pelvic  peritonitis,  inasmuch  as  the  infection  frequently 
first  attacks  the  endometrium.  Pelvic  peritonitis  has  its  starting-point 
less  frequently  in  an  infection  of  the  bowel,  bladder,  vagina,  or  general 
peritoneum.  Traumatisms  of  the  perineum,  cervix,  and  vagina,  incident 
to  parturition  and  surgical  operations,  may  open  the  way  for  infection, 
which  is  conveyed  by  the  bloodvessels  and  lymphatics  to  the  peritoneum. 
The  microorganisms  chiefly  found  in  the  infected  peritoneum  are  those 
common  to  endometritis,  salpingitis,  and  ovaritis — that  is,  the  staphylo- 
coccus pyogenes  albus,  aureus,  and  citreus,  streptococcus  pyogenes, 
gonococcus,  colon  bacillus,  tubercle  bacillus,  Klebs-Loeffler  bacillus, 
pneumococcus,  and  typhoid  bacillus. 

We  w^ill  here  discuss  acute  and  chronic  pelvic  peritonitis,  peritoneal 
exudates,  and  peritoneal  adhesions. 

Acute  pelvic  peritonitis  shows  a  marked  congestion  of  the  bloodvessels 
or  a  diffuse  blush  of  the  peritoneal  surface.  Clinically,  this  stage  is 
recognized  by  intense  pain  and  tenderness  in  the  pelvis,  contraction 
of  the  abdominal  muscles,  tympany,  vesical  and  rectal  tenesmus,  and 
painful  menstruation.  The  temperature  is  elevated,  and  the  pulse 
is  accelerated  in  proportion  to  the  degree  of  temperature  and 
general  intoxication.  Vomiting  and  hiccoughing  are  often  present 
in  advanced  cases,  and  the  patient  lies  with  both  legs  flexed  upon  the 
thighs. 

All  examinations  and  manipulations  should  be  restricted  as  far  as  pos- 
sible in  the  acute  stage.  It  must  be  borne  in  mind  that  acute  exacerba- 
tions of  chronic  peritonitis  will  give  all  the  clinical  evidence  of  a  primary 
acute  attack.  Upon  opening  the  abdomen,  however,  evidences  will 
be  found  of  previous  involvement.  Bandl  says  that  high  fever,  great 
tenderness,  and  tympany  in  the  pelvic  regions  are  sure  signs  of  pelvic 
peritonitis.  It  is  only  after  the  acute  stage  has  subsided  that  a  bimanual 
examination  will  make  sure  that  the  pelvic  connective  tissue  is  not 
diseased  and  that  the  peritoneum  alone  is  affected.  As  a  rule,  the 
early  symptoms  must  be  relied  upon  in  making  the  diagnosis,  for  in 
the  majority  of  cases  no  palpable  exudations  are  found. 

Chronic  pelvic  peritonitis  usually  begins  as  an  acute  infection,  but 
may  be  chronic  from  the  beginning.  Bandl  says:  "The  lesion  can  be 
diagnosticated  in  girls  and  sterile  women  when,  during  the  menstrual 
period  or  at  any  other  time,  with  or  without  fever,  there  exist  deep- 


50G  PERITONITIS 

seated  pain  in  the  pelvis  and  more  or  less  tenderness  over  the  lower 
portion  of  the  abdomen.  If  the  s^^mptoms  are  confined  to  one  side, 
as  is  usually  the  case,  the  process  is  most  probably  present  in  the 
form  of  a  perisalpingitis  and  perioophoritis."  In  the  opinion  of  the 
author,  it  is  not  possible  to  arrive  at  any  intelligent  conclusion  from  the 
above  data  as  to  the  existence  of  chronic  pelvic  peritonitis.  Too  often 
mistakes  are  made  by  rel}'ing  on  the  complaints  of  nervous  and  ignorant 
patients.  A  physical  examination  will  alone  serve  to  differentiate  the 
many  possible  causes  of  such  complaints  as  are  found  in  the  inflamma- 
tory lesions,  the  displacements,  and  the  new-formations  of  the  uterus 
and  adnexse.  The  anatomical  evidences  of  chronic  pelvic  peritonitis 
are  inflammatory  exudates  and  adhesions. 

Peritoneal  exudates  follow  closely  upon  the  initial  acute  stage.  The 
exudate  is  serous,  seropurulent,  or  purulent,  and  may  be  found  to 
occupy  part  or  all  of  the  pelvic  cavity.  The  most  dependent  portion 
of  the  peritoneal  cavity  is  the  cul-de-sac  of  Douglas,  and  into  it  the 
peritoneal  exudate  naturally  gravitates.  It  is  possible  for  such  an 
exudate  to  cause  a  bulging  of  the  posterior  vaginal  fornix,  though  this 
is  not  the  rule  unless  the  underlying  cellular  tissue  is  involved.  In  a 
vaginal  examination  an  exudate  in  the  pouch  of  Douglas  is  found  to 
be  sharply  outlined,  rounded  below,  and  flat  on  the  top.  When  too 
abundant  to  be  wholly  contained  within  the  cul-de-sac,  the  exudate 
spreads  out  upon  the  posterior  surface  of  the  uterus,  may  extend  later- 
ally, and  has  been  known  to  fill  the  entire  inlet  of  the  pelvis.  The 
adherent  and  oftentimes  distended  intestine  gives  an  indefinite  outline 
to  the  upper  border  of  the  exudate. 

The  consistency  of  the  exudate  is  variable.  Fluctuation  may  be 
marked,  or  the  exudate  may  appear  firm,  b}'  virtue  of  the  surrounding 
inflammatory  infiltration. 

In  exceptional  cases  the  exudate  is  located  at  the  side  or  in  front 
of  the  uterus.  It  is  difficult  to  palpate  through  the  vagina  because 
of  its  high  location.  Without  anesthesia  there  is  an  indefinite  sense 
of  resistance  at  the  seat  of  the  exudate.  Under  anesthesia  the  inflam- 
matory mass  may  be  fairly  outlined.  When  a  fluid  exudate  is  encap- 
sulated by  adhesions,  "adhesion  cysts,"  it  is  possible  to  mistake  it 
for  a  sactosalpinx  or  an  ovarian  cyst. 

Peritoneal  adhesions  may  follow  a  serous  or  purulent  exudate,  or 
may  develop  independent  of  a  fluid  exudate.  The  adhesions  may 
involve  any  part  or  all  of  the  pelvic  peritoneum.  They  manifest  great 
variations  in  development,  from  a  delicate  fibrillar  structure  to  dense 
bands.  They  are  more  frequently  found  about  the  adnexse  and  behind 
the  uterus  than  in  front  of  the  uterus,  for  the  reason  that  the  infection 
commonly  travels  through  the  tubes  to  the  peritoneum,  and  it  is  unusual 
for  the  tubes  to  lie  in  front  of  the  uterus. 

Gonorrhea  is  the  most  common  cause  of  adhesions,  and  next  in  point 
of  frequency  is  the  infection  following  labor  and  abortion.  As  a  result 
of  the  adhesions  the  uterus  and  adnexse  are.  more  or  less  fixed,  and  their 
position  is  altered  by  contraction  of  the  adhesions.    With  the  exception 


PELVIC  PERITONITIS 


507 


of  prolapsus  and  inversion  of  the  uterus,  all  varieties  of  malpositions 
are  caused  by  adhesions  about  the  uterus  and  its  appendages. 

CUnical  Diagnosis. — The  clinical  diagnosis  rests  upon  the  physical 
findings.  In  a  conjoined  examination  the  adhesions  are  recognized 
as  cords  and  bands,  rarely  as  a  diffuse  thickening  surrounding  the 
viscera  of  the  pelvis  and  uniting  their  peritoneal  surfaces. 


Peritoneal  adhesions  bind  the  uterus  in  retroposition. 

The  abnormal  fixity  of  the  organs  and  their  displacements  are  sug- 
gestive of  the  presence  of  adhesions.  Not  infrequently  such  fixity  and 
displacements  are  recognized  in  an  examination  without  anesthesia,  and 
it  is  presumed  that  adhesions  exist,  though  they  are  not  accurately 
demonstrated  without  the  administration  of  an  anesthetic. 

When  displacements  of  the  uterus  and  adnexse,  which  have  a  restricted 
range  of  motion,  are  associated  with  tenderness  and  an  indefinite  sense 
of  resistance  at  the  side  of  or  behind  the  uterus,  an  anesthetic  should 
be  administered  to  determine  the  possible  presence  of  adhesions  and 
exudates. 

Differential  Diagnosis. — It  is  at  times  extremeh'  difficult  to  differ- 
entiate a  pelvic  peritonitis  from  a  hyperesthesia  yeritonii  found  in 
women  of  nervous  temperament.  The  general  nervous  state  of  the 
individual,    the   absence    of    all    causes    of   infection,    and    finallv    a 


508  PERITONITIS 

conjoined  examination  under  anesthesia,  will  serve  to  establish  the 
diagnosis. 

A  retroflexed  gravid  uterus  may  be  confounded  with  a  peritonitic 
exudate.  The  fact  of  pregnancy  should  be  determined  by  the  usual 
signs.  In  the  first  trimester  the  cessation  of  menstruation  and  nausea 
are  occasionally  simulated  by  like  complaints  due  to  the  inflammatory 
lesions  about  the  uterus,  in  the  absence  of  pregnancy.  Such  exudates 
are  most  often  found  in  multiparse  in  whom  the  changes  in  the  breast 
are  not  usually  well-marked  during  the  earh'  months  of  pregnancy. 
Of  greatest  importance  are  the  changes  in  size,  form,  consistency, 
and  the  rate  of  growth  of  the  uterus.  An  effort  to  replace  the  uterus, 
with  or  without  anesthesia,  will  determine  the  presence  or  absence 
of  adhesions. 

In  exceptional  cases  a  uterus  fixed  by  adhesions  cannot  be  distin- 
guished from  an  incarcerated  uterus  without  an  exploratory  incision. 
This  is  particularly  true  when  adhesions  bind  the  uterus  loosely  to 
such  movable  structures  as  the  bowel,  omentum,  and  bladder. 

When  the  uterus  is  fixed  and  tender  to  pressure,  adhesions  are  sus- 
pected, even  though  they  cannot  be  felt  under  anesthesia. 

A  retro-uterine  hematocele  may  organize  into  peritoneal  adhesions 
in  the  absence  of  infection.  The  history  and  physical  evidences  of 
an  ectopic  pregnancy,  together  with  the  usual  signs  of  a  hematoma 
and  the  absence  of  a  history  of  infection,  will  serve  to  differentiate 
this  condition  from  true  inflammatory  peritonitic  adhesions. 

Tuberculous  jjeritonitis,  with  encysted  fluid,  according  to  H.  Dure, 
is  differentiated  from  an  ovarian  cyst  by  a  family  history  of  tubercu- 
losis, by  signs  of  the  existence  of  other  tuberculous  lesions,  by  a  history 
of  frequent  abortions  or  of  the  death  of  several  children  from  tuber- 
culosis; and  by  general  symptoms  of  tuberculosis,  such  as  loss  of 
weight,  strength,  and  appetite,  evening  rise  of  temperature,  night 
sweats,  pelvic  pains,  amenorrhea,  leucorrhea,  and  the  previous  occur- 
rence of  salpingo-oophoritis.  The  difterential  diagnosis  of  pelvic 
inflammatory  exudates  from  sactosalpinx  and  ovarian  cysts  is  referred 
to  in  the  chapters  on  Diseases  of  the  Tubes  and  Ovaries. 

Treatment. — The  tendency  of  pelvic  peritonitis  is  to  remain  localized 
and  not  to  spread  to  the  peritoneum  of  the  abdominal  cavity.  It  is 
imperative  that  the  surgeon  should  aid  the  forces  of  nature  in  limiting 
the  infection,  and  should  refrain  from  all  surgical  interference  while 
the  acute  stage  lasts,  unless  pus  is  present  and  can  be  drained  per 
vaginam  without  endangering  the  general  peritoneal  cavity. 

Absolute  rest  should  be  enforced  throughout  the  acute  stage,  ice 
applied  to  the  lower  abdomen,  and  antiseptic  douches  (formalin,  1 
to  2000,  lysol  or  creolin,  0.5  per  cent.,  or  bichloride  of  mercury,  1  to 
2000)  given  at  a  temperature  of  110°  and  repeated  every  four  to  six 
hours,  each  douche  being  twenty  to  thirty  minutes  in  duration.  A 
light  diet  and  daily  evacuations  of  the  bowels  are  essential.  The 
temperature  is  combated  by  cold  sponging. 

AMien  the  acute  stage  has  passed,  the  above  treatment  should  be 


PELVIC  PERITONITIS  509 

pursued,  and  in  addition,  glycerin  and  ichthyol  tampons  should  be 
inserted  three  or  more  times  weekly.  A  detailed  discussion  of  these 
treatments  will  be  found  in  Chapter  XI. 

If  an  abscess  develops  in  the  pelvis  during  the  acute  or  subacute 
stages  and  causes  much  pain  and  sepsis,  the  effort  should  be  made  to 
drain  per  vaginam.  This  procedure  should  be  done  cautiously  for 
fear  of  contaminating  the  general  peritoneal  cavity. 

As  an  argument  against  too  hasty  interference  in  surgery,  we  note 
the  frequent  observation  of  cases  which  have  come  to  a  functional 
cure,  or  have  at  least  been  so  greatly  improved  by  tentative  measures 
and  by  the  lapse  of  time,  that  conservative  operations  have  substituted 
the  more  radical  measures  which  were  at  one  time  contemplated. 

In  all  cases  of  acute  pelvic  peritonitis  the  Fowler  position  should 
be  maintained.  When  there  is  a  high  degree  of  septic  absorption  the 
patient  should  drink  large  quantities  of  water,  and  normal  salt  solution 
should  be  introduced  per  rectum.  The  continuous  administering  of 
salt  solution,  as  advised  by  Murphy,  is  preferred.     (See  page  203.) 

In  the  chronic  stage  of  pelvic  peritonitis  the  treatment  is  both 
tentative  and  surgical.  There  should  be  a  judicious  proportioning  of 
the  means  at  our  command  for  the  relief  of  the  chronic  stage  of  pelvic 
peritonitis.  Surgery  is  invoked  when  tentative  measures  might  suffice, 
and  too  often  these  measures  are  employed  to  the  exclusion  of  surgery. 
A  more  common  error  is  displayed  in  the  failure  to  employ  such  con- 
servative mean  as  rest,  hot  douches,  and  glycerin  and  ichthyol  tampons, 
for  an  extended  period  after  operation.  Failure  in  so  doing  leads  to 
incomplete  cures  in  many  instances. 

In  the  treatment  of  chronic  pelvic  peritonitis  the  associated  lesions 
should  not  be  overlooked.  The  infected  uterus,  tubes,  and  ovaries 
must  be  attended  to  first,  for  they  are  responsible,  in  large  part,  for 
the  manifest  disturbances,  and  without  their  correction  little  can  be 
done  in  the  way  of  affording  relief. 

The  conservative  measures  employed  are  pelvic  massage,  pressure 
therapy,  prolonged  hot  vaginal  douches,  glycerin  and  ichthyol  tampons, 
and  sitz  baths.  (For  a  detailed  discussion  of  these  agencies  see  Chapters 
X  and  XL) 

The  surgery  of  chronic  pelvic  peritonitis  is  largely  involved  in  the 
surgery  of  chronic  metritis  and  salpingo-oophoritis.  When  adhesions 
exist  they  are  to  be  severed  by  the  fingers  or  scissors,  and  all  raw  sur- 
faces carefully  covered  with  peritoneum  when  possible.  The  acutal 
cautery  is  a  fair  substitute  when  used  to  char  the  raw  surfaces. 
Failure  to  observe  these  rules  may  lead  to  the  reformation  of  new 
adhesions,  to  oozing  of  blood,  and  perchance  to  ileus. 


CHAPTER  XXII 

PARAMETRITIS   (PELVIC   CELLULITIS) 

Acute  Parametritis  Varicocele    of    the    Broad    Liga- 

Chronic  Parametritis  ment 

The  loose  connective  tissue  of  the  pelvis  lies  immediately  beneath 
the  peritoneum.  It  surrounds  the  supravaginal  portion  of  the 
cervix,  and  extends  laterally  between  the  layers  of  the  broad  ligament 
and  along  the  sides  of  the  pelvis.  There  is  but  a  small  amount  of 
connective  tissue  in  front  of  the  uterus,  beneath  the  vesico-uterine 
fold  of  peritoneum.  Behind  the  uterus  and  beneath  the  uterorectal 
fold  of  peritoneum  is  a  considerable  amount  of  loose  connective  tissue, 
so  intimately  associated  with  the  rectum,  cervix,  and  vagina  that  it 
frequently  becomes  the  seat  of  infection. 

A  knowledge  of  the  location,  loose  texture,  and  relation  of  the  con- 
nective tissue  to  the  neighboring  structures  will  serve  as  a  basis  for 
our  understanding  of  pelvic  cellulitis. 

Definition. — By  parametritis  is  meant  an  inflammation  of  the  cellular 
tissue  of  the  pelvis.  The  extent  of  the  lesion  varies.  While  sometimes 
diffuse,  it  is  usually  localized.  According  to  the  location  of  the  lesion 
we  recognize  paracystitis,  when  the  limited  amount  of  connective 
tissue  about  the  base  of  the  bladder  is  involved;  paraproctitis,  when 
the  inflammation  is  in  the  cellular  tissue  about  the  rectum ;  paravaginitis, 
when  it  is  about  the  vagina;  posterior  parametritis,  when  in  the  con- 
nective tissue  lying  within  the  uterosacral  folds  and  beneath  the  floor 
of  the  pouch  of  Douglas;  lateral  parametritis,  when  between  the  layers 
of  the  broad  ligament. 

Classification.^ — Freund  classifies  parametritis  as  follows: 
I.  Acute    Inflammation   of   the   Pelvic    Connective    Tissue 

WITH     OR    without     AbSCESS  FORMATION. 

L  Simple  phlegmon. 

2.  Septic    phlegmon. 
^  II.  Chronic  Inflammation  of  the  Pelvic  Connective  Tissue. 

L  Circumscribed  atrophic. 

2.  Diffuse  atrophic. 
The  causes  of  pelvic  cellulitis  are  identical  with  those  of  pelvic 
peritonitis,  and  these  lesions  rarely  exist  singly. 

Acute  Parametritis. — The  initial  symptoms  are  usually  less  violent 
than  in  acute  pelvic  peritonitis.  This  is  particularly  true  of  pain 
and  tenderness.  The  effect  upon  the  pulse  and  temperature  may  be 
equally  severe. 


ACUTE  PARAMETRITIS 


511 


Bandl  says:  "If  a  day  or  two  after  an  attack  of  fever  and  the 
appearance  of  the  initial  symptoms,  the  uterus  is  found  enlarged 
transversely  in  the  region  in  which  the  broad  ligaments  leave  it,  para- 
metritis certainly  exists,  and  it  is  hardly  necessary  to  prove  it  by 
bimanual  examination.  If,  after  fever  has  lasted  for  several  days,  points 
of  resistance  are  found  over  Poupart's  ligament  corresponding  to  the 
seat  of  pain  and  tenderness ;  or  if  swellings  have  formed  above  or  extend 
to  the  centre  of  Poupart's  ligament,  or  internally  to  the  anterior  superior 
spine  of  the  ilium,  the  convex  border  of  which  is  readily  felt  or  even 
seen;  or  if,  by  firm  pressure  on  the  abdominal  wall,  tumors  corresponding 
to  the  broad  ligament  are  found,  then  it  is  also  certain  that  the  process 
involves  the  parametrium.  If  still  doubtful,  the  diagnosis  may  be 
confirmed  by  vaginal  examination,  which  in  most  cases  will  reveal 
the  presence  of  large  masses  at  the  sides  of  the  uterus,  extending 
anteriorly  or  laterally  to  the  pelvic  wall,  or  filling  one  side  of  the  pelvic 
cavity,  showing  clearly  that  the  swellings  felt  through  the  abdominal 
wall  are  masses  of  exudate  extending  below  the  peritoneum." 

Fig.  348 


Contraction  of  the  left  broad  ligament,  drawing  the  uterus  in  a  left  lateral  position. 


In  many  cases  the  exudate  cannot  be  felt  through  the  abdominal 
wall,  because  it  lies  low  in  the  pelvis  and  is  only  to  be  palpated  through 
the  vagina.  "If,  with  more  or  less  inflammatory  symptoms,  masses 
form  in  the  neighborhood  of  the  cervix,  or  extend  to  the  deeper  portions 
of  the  pelvis,  being  doughy  and  soft  at  the  beginning,  but  rapidly  becom- 
ing harder,  or  if  large,  w^ell-defined  swellings  form  in  the  true  pelvis, 
in  front  of  or  behind  the  uterus,  the  process  can  be  none  other  than 
phlegmonous  inflammation  of  the  cellular  tissue."     (Bandl.) 


512 


PARAMETRITIS 


Chronic  Parametritis. — Chronic  parametritis  is  diagnosticated  from 
the  position  and  consistency  of  the  exudate  and  from  its  relation  to 
neighboring  structures.  The  history  of  the  infection,  together  with 
the  general  and  local  symptoms,  can  no  more  than  suggest  the  prob- 
able nature  of  the  lesion. 

Position  of  the  Exudate. — The  exudate  occupies  the  position  of  the 
pelvic  connective  tissue  with  greatest  frequency  in  localities  in  which 
the  connective  tissue  is  most  abundant,  namely,  behind  the  uterus 
and  between  the  layers  of  the  broad  ligaments.  In  either  case  the 
exudate  lies  low  in  the  pelvis. 

Fig.  349 


Perityphlitic  adhesions.     Uterus  and  appendages  are  not  involved. 


When  involving  the  connective  tissue  at  the  base  of  the  broad  liga- 
ments, the  exudate  spreads  to  the  sides  of  the  pelvis.  Behind  the  uterus 
it  bulges  down  into  the  vagina,  forming  a  rounded,  tender  swelling 
in  the  cul-de-sac.  When  involving  the  connective  tissue  at  the  sides 
of  the  pelvis,  it  spreads  into  a  flat  mass  which  extends  from  the  sides 
of  the  uterus  toward  the  sides  of  the  pelvis. 

It  is  possible  for  the  exudate  to  dissect  in  front  and  behind  in  the 
subperitoneal  connective  tissue  of  the  abdominal  wall.  It  is  impossible 
for  the  exudate  to  burrow  above  the  umbilicus,  because  at  this  level 
the  subperitoneal  connective  tissue  disappears.  Furthermore,  the  dis- 
section cannot  go  beyond  the  median  line  of  the  abdominal  wall.  In 
this  manner  an  abscess  may  burrow,  there  being  a  greater  tendency 


CHRONIC  PARAMETRITIS 


513 


on  the  part  of  purulent  collections  to  gravitate  to  a  lower  level  than 
is  the  case  with  non-suppurative  exudates.  The  abscess  may  finally 
be  discharged  through  the  bladder,  vagina,  rectum,  abdomen,  or  through 
one  of  the  pelvic  foramina. 

The  form  of  the  exudate  varies  according  to  its  consistency  and 
location,  and  moulds  itself  to  neighboring  structures.  Beneath  the 
cul-de-sac  of  Douglas  it  is  somewhat  rounded  because  of  the  limited 
resistance  offered  by  the  surrounding  soft  structures.  Between  the 
resisting  layers  of  the  broad  ligaments  the  exudate  is  flattened,  and 
the  same  is  true  to  a  greater  degree  at  the  sides  of  the  pelvis.  As  the 
exudate  is  absorbed  its  form  changes,  because  the  absorption  proceeds 
irreffularlv. 


Fig.  350 


Inflammatory  exudate  in  right  broad  ligament. 


Mobility  of  the  exudate  is  scarcely  perceptible.  If  attached  by  a 
broad  base  to  an  immovable  structure,  the  exudate  will  be  firmly  fixed. 
A  small  exudate  within  the  broad  ligament  may  show  some  degree 
of  mobility,  but,  as  a  rule,  we  speak  of  cellular  exudates  as  fixed  and 
immovable. 

The  consistency  is  also  subject  to  great  variations,  depending  upon 
the  character  of  the  exudate,  whether  edematous,  fibrinous,  or  purulent. 
It  may  be  soft  and  fluctuating,  and  again  as  firm  as  cartilage.  In  the 
early  development  of  the  exudate  the  consistency  is  elastic  and  yielding ; 
later  it  becomes  firm  from  organization  and  contraction.  If  suppura- 
33 


514 


PARAMETRITIS 


tion  ensues  there  will  be  a  boggy  and  possibly  fluctuating  mass.  The 
consistency  is  best  determined  by  rectal  and  vaginal  palpation. 

Tenderness  to  pressure  is  characteristic  of  all  inflammatory  lesions. 
Large  exudates  may  exist  with  little  tenderness,  but  tenderness  is  a 
reliable  guide  to  the  inflammatory  character  of  the  mass. 

The  relation  of  the  exudate  to  neighboring  organs  is  important 
in  difi^erentiating  from  new  formations  in  the  pelvis.  The  exudate 
blends  intimately  with  adjacent  structures  and  cannot  be  outlined 
apart  from  them.  In  intraligamentous  exudates  the  mass  lies  snugly 
against  the  side  of  the  uterus,  sometimes  surrounding  the  supravaginal 
portion  of  the  cervix,  but  never  extending  to  the  fundus.     In  para- 


FiG.  351 


Appendicular  exudate. 


vaginitis  it  may  be  impossible  to  move  the  vaginal  mucosa  from  the 
exudate.  In  paraproctitis  the  exudate  may  bulge  into  the  rectum, 
narrowing  the  bowel  lumen,  and  so  intimately  blend  with  the  wall  of  the 
rectum  that  it  moves  as  one  mass.  In  the  absorption  of  the  exudate 
the  periphery  is  first  to  disappear.  In  an  intraligamentous  exudate  the 
mass  may  retreat  from  the  side  of  the  pelvis  and  form  an  elongated  or 
rounded  swelling,  firmly  adherent  to  the  uterus. 

Differential  Diagnosis. — The  distinction  between  a  perimetric  and 
a  parametric  exudate  is  at  all  times  difficult.  Certain  well-defined 
points  of  distinction  serve  to  differentiate  the  two  lesions,  but  they 
commonly  coexist. 


CHRONIC  PARAMETRITIS 


515 


Parametritis 

1.  Exudate  lies  low  in  the  pelvis. 

2.  Pain  may  not  be  great,  and  is  dull  and  con- 

tinuous. 

3.  Exudate  commonly  at  the  side  of  the  uterus, 

never  extending  to  the  fundus. 

4.  Exudate    of    firm    consistency;    tendency    to 

suppuration. 

5.  Uterus  partially  fixed. 

6.  Tympanites  usually  absent. 

7.  Facial  expression  may  be  natural. 

8.  Nausea  and  vomiting  not  common. 

9.  One  leg  flexed. 


Pelvic  Peritonitis 

1.  Lies  high  in  the  pelvis. 

2.  Pain  usually  more  intense,  sharp,  lancinating 

and  paroxysmal. 

3.  Exudate  commonly  behind  the  uterus,  often 

extending  to  the  fundus. 

4.  Commonly   less   firm;   no   great   tendency   to 

suppurate. 

5.  Uterus  may  be  firmly  fixed. 

6.  Tyinpanites  usually  present. 

7.  Facial  expression  anxious. 

8.  Nausea  and  vomiting  present. 

9.  Both  legs  flexed. 


Retro-uterine  Parametritis 

1.  Outline  rounded  below   and   sharply   circum- 

scribed. 

2.  Exudate  cannot  extend  to  fundus. 

3.  Uterus  may  be  crowded  forward;  usually  only 

the  cervix  is  crowded  forward. 

4.  Rectum    firmly    and    closely    surrounded    by 

exudate  in  front  and  at  the  side. 

5.  Mucosa  of  rectum  does  not  move  upon   the 

exudate. 

6.  Posterior  vaginal  fornix  depressed. 


Retro-uterine  Perimetritis 

1.  Outline  diffuse,  not  sharply  circumscribed. 

2.  Exudate  may  extend  above  fundus. 

3.  Uterus    may    be    crowded    forward    by    the 

exudate  or  drawn  backward  by  adhesions. 

4.  Rectum  crowded  backward  by  exudate. 

5.  Mucosa  moves  independently  of  the  mass. 

6.  Usually  not  depressed. 


A  yaratyphlitic  exudate  is  not  infrequently  confounded  with  an 
intraligamentous  parametritis.  It  is  possible  for  a  paratyphlitic  exudate 
to  burrow  between  the  layers  of  the  broad  ligament  to  the  side  of 
the  uterus. 


Perityphlitis 

1.  Initial  symptoms:  nausea,  vomiting,  constipa- 

tion, fever,  pain  at  Mcliurney's  point. 

2.  Tendency  of    a  perityphlitic  abscess  to  rup- 

ture into  the  bowel  and  peritoneal  cavity. 

3.  Tendency  to  recurrence. 

4.  Exudate  lies  high  on  the  right  side  and  spreads 

from  above  downward. 


Parametritis 

1.  Initial    symptoms:    fever,    constipation,    pain 

low  in  the  pelvis  at  the  .side  of  the  uterus, 
rarely  nausea  and  vomiting. 

2.  Little    tendency    to    rupture   into   the   bowel 

and  peritoneal  cavity. 

3.  Tendency  to  recurrence  not  so  great. 

4.  Exudate   hes  lows  in  the   pelvis  and   spreads 

from  below  upward. 


A  ijehic  hemato7na  may  so  closely  resemble  a  parametric  exudate 
as  to  be  indistinguishable  without  an  exploratory  incision  or  puncture. 
Both  lesions  are  confined  to  the  cellular  tissue  of  the  pelvis,  and  in 
general  contour,  size,  and  consistency  they  may  be  quite  similar.  The 
following  tabulated  points  will  usually  serve  to  differentiate  the  two: 


Pelvic  Hematoma 

1.  Develops  suddenly. 

2.  History  of  ectopic  pregnancy. 

3.  Onset  marked  by  normal  or  subnormal  tem- 

perature and  rapid,  feeble  pulse. 

4.  Exudate  usually  beside  the  uterus  and  circum- 

scribed. 

5.  Exudate    at   first   doughy,    later    firm,    never 

tender  unless  infected. 

6.  Exploratory  puncture — blood. 


Parametritis 

1.  Develops  more  gradually. 

2.  Absent. 

3.  Onset   marked    by   rise    of    temperature    and 

increased  pulse  rate. 

4.  Exudate  beside  or  behind  the  uterus  and  less 

circumscribed. 

5.  Exudate  firmer  and  tender. 


6.  Exploratory  puncture- 
tive. 


-serum,  pus,   or  nega- 


Suhserous  fibroids  may  be  confounded  with  a  parametric  exudate. 
When  the  exudate  is  round  and  attached  by  a  broad  base  to  the  uterus 
and  not  especially  tender  to  pressure,  the  diagnosis  is  difficult,  and  may 
not  be  cleared  up  without  an  exploratory  incision.  The  difficulty  in 
diagnosis  is  especially  great  in  intraligamentous  fibroids.  The  more 
movable  the  mass,  the  more  likely  it  is  to  be  a  fibroid.     In  a  cellular 


516  PARAMETRITIS 

exudate  there  is  a  history  of  infection  and  the  mass  grows  rapidly. 
But  in  fibroids  there  is  no  history  of  infection,  and  the  growth  develops 
slowly.  The  depth  of  the  uterine  cavity  is  usually  increased  in  uterine 
fibroids'  beyond  that  found  in  parametritis.  The  effects  of  treatment 
will  aid  in  the  diagnosis;  in  parametritis  the  mass  should  diminish  under 
treatment,  while  in  fibroids  little, or  no  effect  will  be  observed. 

Malignant  disease  of  the  pelvis,  involving  the  parametrium,  may 
arise  from  a  primary  focus  in  any  of  the  pelvic  viscera.  There  is  absence 
of  a  history  of  infection,  no  acute  onset  being  experienced,  and  there 
are  present  the  general  symptoms  of  malignancy  rather  than  of  infection. 
The  primary  seat  of  malignancy  can  usually  be  determined,  and  the 
hard,  irregular  character  of  the  infiltrated  area  will  serve  to  indicate 
the  condition. 

Parametritis  Pso.'VS  Abscess 

1.  Usually  of  acute  origin.  1.   Usually  of  chronic  origin. 

2.  Absence  of  spondylitis.  2.   Spondylitis  present. 

3.  Exudate  tender  to  pressure.  3.  Exudate  not  tender  to  pressure. 

■1.  Fluctuation  may  be  absent;  induration  about       4.  Fluctuation  only  occasional;  no  hard  exudate 
abscess  always  present.                                                          about  abscess. 

5.  Thigh  flexed,  not  rotated.  5.  Thigh  flexed  and  rotated  inward. 

6.  Temperature  may  be  high.  6.  Temperature  absent  or  slight  rise,  especially 

in  the  morning. 

7.  Exploratory  puncture  shows  absence  of  tuber-       7.  Presence  of  tuberculous  exudate  and  possibly 

culous  exudate  and  tubercle  bacilli.  tubercle  bacilli. 

S.  Tuberculin  give.s  no  reaction.  S.  Tuberctilin  usually  gives  a  reaction. 

Treatment. — The  treatment  of  pelvic  cellulitis  is  in  many  respects 
similar  to  that  of  pelvic  peritonitis. 

In  acute  pelvic  cellulitis  identical  conservative  measures  are  practised. 
The  patient  is  confined  to  her  bed,  an  ice-bag  is  placed  over  the  hypo- 
gastrium,  oft-repeated  hot  vaginal  douches  are  administered,  the  diet 
is  restricted,  and  the  bowels  freely  opened.  As  the  acute  stage  passes 
away,  glycerin  and  ichthyol  tampons  are  applied  daily. 

If  an  abscess  develops  it  should  be  drained  per  vaginam.  (See 
page  517.) 

"When  the  pain  is  severe  opium  suppositories  or  hypodermic  injec- 
tions of  morphine  must  be  administered. 

In  chronic  pelvic  cellulitis  the  treatment  consists  in  the  usual  conser- 
vative measures  employed  in  the  management  of  chronic  pelvic  inflam- 
mation in  general.  Prolonged  hot  vaginal  douches,  ichthyol  and 
glycerin  tampons,  pelvic  massage,  and  pressure  therapy  are  applied 
in  accordance  with  the  rules  laid  down  in  Chapters  X  and  XI.  When 
ajielvic  abscess  exists  it  should  be  drained.     (See  page  517.) 

Treatment  of  Pelvic  Abscess. — The  treatment  of  abscesses  resident  in 
the  pelvic  peritoneal  cavity  or  in  the  pelvic  connective  tissue,  exclusive 
of  pyosalpinx  and  ovarian  ab.scess,  is  drainage  per  vaginam. 

This  is  by  no  means  a  minor  procedure,  in  that  it  must  be  eftectually 
done  and  without  injury  to  neighboring  structures  or  contamination 
of  the  general  peritoneal  cavity. 

The  more  acute  the  infection  the  greater  the  danger  of  its  extension, 
and  the  higher  the  location  of  the  abscess,  the  more  difficult  the  opera- 


PLATE    XXV 


Method  of  Packing  Douglas'  Pouch  for  Drainage  in 
Cases  of  Pelvic  Abscess. 


VARICOCELE  OF  THE  BROAD  LIGAMENTS  517 

tioii  and  the  greater  the  danger  of  injuring  the  surrounding  structures, 
especially  the  bowel. 

Two  or  more  separate  abscesses  may  exist,  and  it  is  important  that 
an  outlet  common  to  all  of  them  should  be  made. 

Techiic. — The  vulva  and  vagina  are  prepared  in  the  usual  manner 
for  operation.  It  is,  as  a  rule,  advisable  to  give  a  general  anesthetic, 
though  the  operation  may  be  performed  without  anesthesia  when  the 
patient  is  greatly  depressed. 

The  cervix  is  exposed  by  a  hanging  speculum  and  two  lateral 
retractors.  The  posterior  lip  of  the  cervix  is  grasped  by  a  vulsellum 
forceps  and  firm  traction  is  made  forward  and  upward.  The  vaginal 
wall  is  grasped  by  tissue  forceps  at  a  point  immediately  back  of  the 
cervix,  and  with  sharp-pointed  scissors  a  transverse  incision  is  made 
in  the  posterior  fornix  of  the  vagina  close  to  the  cervix.  This  incision 
extends  through  the  wall  of  the  vagina  only,  and  is  about  one  inch  in 
length. 

A  strip  of  gauze  is  then  draped  over  the  index  finger  and  by  the 
finger  the  opening  is  stretched,  the  connective  tissue  is  stripped  from 
the  cervix,  and  the  finger  directed  to  the  seat  of  the  abscess. 

Having  opened  into  the  abscess  with  the  finger  the  drainage  is  made 
more  free  by  stretching  the  tissues.  A  careful  digital  exploration  is 
made  in  view  of  the  possible  finding  of  other  accumulations  of  pus, 
and  when  found  they,  too,  are  opened  and  drained. 

When  the  abscess  lies  high  in  the  pelvis  it  may  be  necessary,  in  order 
to  reach  it,  to  pass  long  blunt  forceps  beyond  the  reach  of  the  finger, 
and  when  the  abscess  has  been  entered,  the  forceps  is  spread  to  allow 
the  free  escape  of  the  contained  pus.  This  is  a  dangerous  procedure, 
and  one  that  recjuires  experience  and  skill.  In  exceptional  cases  the 
abscess  should  be  opened  above  Poupart's  ligament. 

After  making  a  free  opening  through  the  cul-de-sac  into  the  abscess, 
the  cavity  is  packed  with  a  long  strip  of  antiseptic  gauze.  The  author 
advises  against  irrigating  the  abscess  cavity,  immediately  after  opening, 
for  fear  of  spreading  the  infection. 

The  gauze  pack  should  be  removed  at  the  end  of  forty-eight  hours 
and  a  vaginal  douche  given.  So  long  as  the  abscess  drains  freely,  only 
antiseptic  vaginal  douches  should  be  given,  but  if  free  drainage  is 
interrupted,  the  incision  should  be  spread  with  fingers  or  forceps  and 
the  cavity  washed  out  with  an  antiseptic  solution.  When  it  is  difficult 
to  obtain  continuous  free  drainage  a  fenestrated  rubber  drainage-tube 
should  be  inserted  and  the  cavity  irrigated  daily  through  the  tube. 
In  all  acute  pelvic  abscesses  the  patient  should  be  kept  in  the  Fowler 
position. 

After  the  abscess  has  completely  drained,  the  surrounding  inflam- 
matory tissue  should  be  treated  with  vaginal  douches  and  glycerin  and 
icthyol  tampons. 

Varicocele  of  the  Broad  Ligaments. — ^'aricocele  of  the  broad  ligaments 
is  rarely  met  with  independent  of  other  pelvic  or  abdominal  lesions. 
The  ovarian  \'eins  are  known  to  undergo  great  enlargement  in  pregnancy, 


518  PARAMETRITIS 

and  it  might  be  expected  that  these  veins  would  occasionally  fail  to 
involute  in  the  puerperium.  As  the  result  of  sexual  excitement  and 
menstruation  the  veins  of  the  broad  ligaments  become  overdistended. 
These  factors  may  lead  to  permanent  overdistention  of  the  veins. 
The  following  conditions  are  mentioned  as  etiological  factors: 

1.  General  Causes. — Incompetent  heart,  diseases  of  the  lungs,  kidneys, 
spleen,  and  liver,  which  lead  to  a  sluggish  pelvic  circulation. 

2.  Local  Causes. — Subinvolution  of  the  uterus,  pelvic  inflammation, 
abdominal  tumors  and  ascites,  extensive  lacerations  of  the  cervix 
into  the  broad  ligaments,  uterine  displacements,  chronic  constipation, 
and  tight-lacing;  all  of  which  tend  to  engorge  the  pelvic  veins. 

Symptoms. — The  symptoms  are  usually  marked  by  those  emanating 
from  the  associated  lesions.  There  is  a  sense  of  weight  and  fulness  in 
the  pelvis  which  is  commonly  referred  to  the  iliac,  sacral,  and  perineal 
regions.  This  feeling  of  discomfort  is  aggravated  by  long  standing 
and  is  relieved  by  lying  down. 

Diagnosis. — The  symptoms  recorded  above  will  be  highly  suggestive. 
The  diagnosis  is  not  usually  made  before  the  abdomen  is  opened,  and 
is  then  often  overlooked,  because  in  the  Trendelenburg  position  the 
veins  are  collapsed.  It  is  sometimes  possible  to  make  the  diagnosis 
by  palpating  at  the  sides  of  the  uterus  a  yielding  compressible  mass, 
varying  in  size  to  that  of  a  hen's  egg. 

Treatment. — All  associated  conditions  demand  consideration.  Con- 
servative measures  may  afford  relief;  such  are  the  introduction  of  a 
pessary  to  correct  a  displaced  uterus,  the  depletion  of  the  pelvis  by 
catharsis,  hot  vaginal  douches,  and  rest. 

Operative  treatment,  in  event  of  failure  of  the  conservative  measures, 
consists  in  multiple  ligatures  with  linen  along  the  course  of  the  dis- 
tended veins.  The  author  does  not  find  it  either  necessary  or  advisable 
to  dissect  out  the  distended  veins. 


CHAPTER  XXIII 
GONORRHEA  IX  WOMEN 

Historical  Sketch  Prognosis 

GoNOCoccus  OF  Neisser  i  Prophylaxis 

Etiology  j  Treatment 

Diagnosis  !  Gonorrhea  in  Children 

Historical  Sketch. — The  prevalence  of  gonorrhea  was  not  fully 
appreciated  before  Noeggerath  made  known  his  clinical  observations 
in  New  York  City,  in  1877.  Two  years  later  Neisser  identified  the 
gonococcus  as  the  essential  causal  factor  and  made  possible  the  recog- 
nition of  latent  cases  which  hitherto  had  not  been  recognized. 

The  statistics  of  Noeggerath  created  a  furore  of  criticism  and  ridicule. 
He  stated  that  80  per  cent,  of  married  men  have  had  gonorrhea,  that 
90  per  cent,  of  these  have  never  been  healed,  and  that  of  five  married 
women,  three  have  gonorrhea.  Zweifel  and  Sanger  took  issue  with 
Noeggerath  and  estimated  that  18  per  cent,  of  married  women  have 
gonorrhea.  The  author  is  convinced  that  the  truth  lies  between  the 
statements  of  Noeggerath  and  those  of  Zweifel  and  Sanger. 

Gonococcus  of  Neisser. — The  gonococcus  of  Neisser  is  a  diplococcus 
averaging  1.25  mm.  in  diameter,  with  an  interspace  of  about  0.8  mm. 
between  the  two  halves  of  the  organism.  Occasionally  grouDS  of  four 
cocci  are  seen,  and  more  rarely  single  cocci  exist.  The  organism  grows 
best  at  body  heat,  but  its  growth  is  not  retarded  at  freezing  temperature 
or  at  a  corresponding  high  temperature.  It  will  not  grow  on  gelatin  or 
agar,  but  on  blood  serum  plus  peptone-agar  (Wertheim)  the  organism 
grows  slowly.  It  grows  in  a  neutral,  slightly  alkaline,  or  faintly  acid 
medium.  When  dry  it  soon  perishes,  hence  the  dried  secretions  soon 
lose  their  virulence.  The  gonococcus  can  exist  in  the  tissues  throughout 
the  lifetime  of  the  individual,  and  at  any  time  under  favorable  influences 
the  infection  may  light  up  into  what  appears  to  be  a  new  and  acute 
infection,  or  may  transmit  a  virulent  infection  without  itself  becoming 
manifest. 

Etiology. — Frequency. — Wolbarst  says  that  75  to  90  per  cent,  of  all 
gynecological  operations  are  occasioned  by  gonorrhea.  The  number 
of  gonorrheics  in  New  York  City  is  estimated  at  225,000  to  800,000. 
It  is  estimated  by  Gerrish  that  in  New  York  City  in  1900,  225,000  men 
and  women  died  from  gonorrhea  and  sj'philis.  Hoff  estimated  an 
increase  of  50  per  cent,  of  venereal  diseases  in  the  United  States  Army 
in  the  period  in  1899  to  1905. 

The  section  in  Hygiene  and  Sanitary  Science  of  the  American  ]\Iedical 
Association  reported  in  1901  that  in  the  experience  of  many  European 


520  GONORRHEA   IX    WOMEN 

and  American  i;ynea)log'ists,  40  per  cent,  of  women  suffering  from 
pelvic  inflammation  have  gonorrhea.  Wolbarst  makes  the  startHng 
statement  that  70  per  cent,  of  married  women  who  complain  of  pelvic 
disorders  have  acquired  gonorrhea   innocently  from  their  husbands. 

Extracougucjal  Infections. — It  is  exceptional  for  gonorrhea  to  be 
conveyed  by  means  other  than  sexual  intercourse.  Gonorrhea  may 
be  conveyed  to  the  eyes  of  the  newborn.  The  bathroom  is  an  occasional 
source  of  contagion,  and  cases  have  been  traced  to  the  dispensary  and 
office  where  the  instruments  and  hands  of  the  examining  physician 
were  not  properly  cleansed.  Children  attended  by  infected  mothers 
and  maids  are  sometimes  contaminated. 

Immunity. — Immunity  may  be  acquired,  though  an  individual  may 
be  repeatedly  infected.  General  immunity  to  gonorrheal  infection 
does  not  exist.  Certain  tissues,  notably  gland  tissues,  appear  to  be 
immune.  Local  immunity  in  certain  tissues,  notably  the  mucosa  of 
the  urethra,  is  said  to  exist  for  a  brief  time;  however,  this  fact  is  not 
fully  established.  A  second  infection  may  soon  follow  the  first.  The 
immunity  exists  only  so  long  as  the  tissues  are  under  the  direct  influence 
of  the  gonotoxins  or  of  gonococci. 

The  discharge,  accompanying  a  chronic  gonorrheal  urethritis  or 
endometritis,  is  proved  to  be  virulent  only  when  the  microscope  reveals 
the  presence  of  gonococci  or  when  sexual  intercourse  results  in  infection. 
The  amount  of  the  discharge  or  its  constancy  does  not  indicate  the 
degree  of  virulence.  We  have  demonstrated  the  presence  of  the  gono- 
coccus  in  the  absence  of  a  discharge,  and  we  have  failed  to  detect  the 
gonococcus  in  the  presence  of  a  chronic  discharge. 

Individuals  have  been  known  to  infect  others,  yet  apparently  are 
themselves  immune  to  infection.  The  explanation  lies  in  the  presence 
of  a  chronic  gonorrheal  infection,  in  the  absence  of  all  clinical  signs. 
In  the  first  individual  the  gonococcus  had  little  virulence,  but  when 
transmitted  to  sterile  tissues  it  assumed  an  active  role. 

Husband  and  wife  may  both  be  infected,  neither  manifesting  symp- 
toms of  the  disease,  yet  a  third  individual  having  intercourse  wdth  one 
or  the  other  may  acquire  a  virulent  infection.  Again,  the  husband 
may  infect  his  wife,  then  have  no  intercourse  wdth  her  until  he  is  appar- 
ently cured,  when  on  resuming  sexual  relations  with  his  wdfe  wiiom 
he  had  previously  infected,  he,  in  turn,  is  inoculated  by  her. 

A  gonococcus  of  low  virulence  when  transferred  to  a  second  individual 
may  acquire  added  virulence.  In  this  manner  a  husband,  w^ho  is  the 
carrier  of  a  latent  unrecognized  infection,  may  infect  his  wife  and  in 
turn  become  acutely  infected. 

Period  of  Inoculation. — It  is  not  possible  to  establish  a  definite  period 
of  inoculation,  but  it  is  said  to  vary  from  twelve  hours  to  a  ,week  or 
more.  Experimental  inoculations  with  pure  cultures  of  the  gonococcus 
have  created  an  inflammatory  reaction  in  twelve  to  twenty-four  hours. 

Pathology. — In  the  urethra  w^e  find,  during  the  acute  stage,  that  the 
gonococcus  advances  by  way  of  the  intercellular  spaces  to  the  deeper 
structures  of  the  mucosa  and  into  the  underlying  connective  tissue. 


PATHOLOGY  521 

As  the  acute  stage  merges  into  the  chronic,  there  is  a  less  diti'use  dis- 
tribution of  the  organism  and  the  leucocytes,  the  gonococci  confining 
themselves  to  isolated  areas  in  the  superficial  structures,  particularly 
those  areas  which  present  to  the  unaided  eye  congested  and  ulcerated 
regions. 

Infection  of  the  glands  of  the  urethra  is  of  frequent  occurrence 
and  presents  a  serious  complication  because  it  is  in  these  follicles  that 
the  gonococcus  may  reside  for  an  indefinite  time  and  elude  all  the 
ordinary  means  of  treatment.  Skene's  ducts  and  para-urethral  glands 
frequently  give  origin  to  retention  cysts  and  abscesses.  Caruncles  grow 
in  the  anterior  third  of  the  urethra  as  the  result  of  constant  irritation. 
These  sensitive  growths  are  single  or  multiple,  and  are  composed  of  a 
loose  vascular  infiltrate  covered  with  mucosa.  Erosions,  red  areas, 
and  gray  plaques  may  be  seen  distributed  irregularly  over  the  surface 
in  chronic  gonorrheal  urethritis.  The  urethral  wall  may  present  a 
diffuse  or  circumscribed  area  of  infiltration,  which  in  healing  may 
develop  sclerosed  bands.  It  is  rare,  however,  to  find  a  well-developed 
infiammatory  stricture  in  the  female  urethra.  The  author  has  never 
observed  one. 

The  surfaces  of  the  genital  tract  which  are  covered  by  stratified, 
squamous  epithelium,  /.  e.,  vulva,  vagina,  and  vaginal  portion  of  the 
cervix,  evince  a  peculiar  resistance  to  gonorrheal  infection  during  the 
period  of  sexual  maturity.  In  infancy  and  old  age  the  epithelium  has 
a  much  lower  resistance,  and  primary  gonorrheal  vulvovaginitis  is 
not  uncommon. 

In  the  height  of  the  infectious  process  the  papillae  are  crowded  with 
small  round  cells.  On  the  surface  of  the  mucosa  is  a  deposit  of  pus 
cells  and  cellular  debris,  and  in  this  deposit  are  found  gonococci  in 
varying  numbers.  These  organisms  extend  into  the  intercellular 
spaces  of  the  epithelium,  but  have  not  been  demonstrated  to  invade 
the  underlying  connective  tissue. 

The  vulvar  glands,  which  may  be  found  in  great  numbers  in  ad^'ance 
of  the  hymen  and  in  the  fossa  navicularis,  may  be  infected  and  form 
shot-like  elevations  from  which  pus  can  be  expressed.  The  term 
folliculite  vulvaire  blennorrhagiqiie  has  been  applied  to  this  lesion  by 
Record,  Rollete,  and  ]Martineau.  The  gonococcus  has  been  found  in 
the  expressed  pus. 

Gonorrheal  folliculitis  of  the  vulva  may  result  in  the  formation  of 
fistulse  by  the  opening  of  these  abscesses  into  the  vagina  and  bowel. 
Such  a  condition  is  rare. 

The  Bartholinean  glands,  which  are  frequently  involved,  are  said 
by  Bumm  not'  to  be  deeply  invaded  by  the  gonococcus.  According  to 
Gebhard,  all  deep-seated  infections  of  the  Bartholinean  glands  are 
the  result  of  mixed  infections  of  the  gonococcus  and  staphylococcus. 

In  the  uterus  numerous  groups  of  gonococci  were  seen  to  occupy 
spaces  between  the  superficial  epithelial  cells  and,  to  a  lesser  extent, 
the  intercellular  connective-tissue  spaces.  ]Madlener  made  histological 
observations  in  a  case  ten  weeks  after  the  initial  infection,  which  was 


522  GONORRHEA  IN  WOMEN 

the  seventh  week  of  the  puerperium.     In  this  case  gonococci  were 
distributed  throughout  the  entire  uterine  musculature. 

In  the  Falloinan  tubes  the  gonococcus  has  been  repeatedly  recognized 
in  the  pus  contained  within  the  lumen  of  the  tubes  and  in  the  mucous 
lining.  Morax  and  Raymond  found  the  gonococcus  in  the  superficial 
layer  of  the  mucosa.  Bumm  found  nests  of  gonococci  in  the  mesosalpinx, 
as  did  also  Wertheim. 

The  ovary  is  rarely  attacked  by  the  gonococcus  in  the  absence  of  a 
previously  infected  tube.  Under  rare  conditions  the  ovary  may  be 
attacked  by  way  of  the  peritoneum,  the  microorganisms  passing  through 
the  intact  germinal  epithelium  of  the  ovary  or  into  the  open  follicles. 
Again,  it.  is  possible  for  the  gonococcus  to  pass  through  the  uterus  by 
way  of  the  lymph  vessels  of  the  broad  ligaments  to  the  hilum  of  the 
ovary. 

Peritoneum. — Localized  pelvic  and  general  abdominal  peritonitis, 
due  to  gonorrheal  infection,  has  rarely  been  demonstrated  by  bac- 
teriological observations,  though  clinically  it  is  well  known.  Cases 
of  general  gonorrheal  peritonitis  are  reported  by  Koehler,  Frank, 
Gushing,  Veit,  and  Menge.  Hunner  and  Harris  reported  seven  cases, 
and  gave  an  analysis  of  thirty-nine  previously  reported  cases. 

Little  is  known  of  gonorrheal  infection  of  the  pelmc  connective  tissue. 
That  gonorrheal  abscesses  do  form  in  connective  tissue  is  demonstrated 
by  Wertheim,  Dinkier,  and  Jadessohn,  but  the  bacteriological  observa- 
tions which  have  been  carried  on  in  cases  of  pelvic  cellulitis  of  gonorrheal 
origin  have  led  to  great  confusion. 

The  bladder  is  seldom  attacked  by  -  the  gonococcus.  Wertheim, 
Bierhoff,  Barlow,  and  others  have  all  recognized  the  lesion.  Wertheim 
has  demonstrated  the  presence  of  gonococci  in  the  intercellular  spaces 
and  in  the  bloodvessels  of  the  bladder  wall.  It  is  at  the  base  of  the 
bladder  that  the  lesion  commonly  exists,  though  a  generalized  gonorrheal 
cystitis  has  been  recognized  by  a  large  number  of  observers. 

The  urine  contains  a  variable  amount  of  pus  and  bladder  epithelium, 
sometimes  red  blood  cells,  and  is  alkaline  in  reaction.  In  the  acute 
stage  gonococci  are  usually  found  in  the  pus  cells. 

Baier  found  the  rectum  involved  in  30  per  cent,  of  191  cases  of  gon- 
orrhea. Fissures,  erosions,  and  ulcers  may  accompany  a. swelling  of 
the  rectal  mucosa.  The  majority  of  cases  are  not  recognized  for  want 
of  a  bacteriological  examination  of  the  mucous  secretions  of  the  rectum. 
In  nearly  every  instance  the  genito-urinary  tract  is  likewise  infected. 

Diagnosis. — The  diagnosis  of  the  presence  of  a  gonorrheal  infection 
is  generally  an  easy  task,  but  it  is  difficult  to  determine  the  extent  to 
which  the  infection  has  spread. 

History. — It  is  possible  to  make  a  practically  correct  diagnosis  from 
the  history  alone.  A  recently  married  woman  may  complain  of  leu- 
corrhea  and  burning  pain  on  urinating,  and  it  is  learned  that  her 
husband  w^as  at  one  time  infected.  In  such  cases  there  is  little  doubt 
of  the  existence  of  gonorrhea,  but  without  a  physical  examination  the 
diagnosis  cannot  be  established,  nor  is  it  known  how  far  the  infection 


DIAGNOSIS 


523 


has  extended.  A  woman  may  acquire  a  gonorrheal  infection  without 
her  knowledge  and  in  the  absence  of  all  local  and  general  signs;  hence 
the  uncertainty  of  relying  upon  the  history. 

Gonorrheal  Urethritis. — The  acute  attack  is  ushered  in  by  a  tickling 
and  burning  sensation  before  and  after  urinating.  There  is  a  trans- 
parent serous  secretion,  in  which  pus  cells,  desquamated  epithelium, 
and  gonococci  are  found  in  variable  numbers.  By  the  end  of  the  third 
day  the  secretion  becomes  thick  and  yellow.  There  is  tenderness  along 
the  course  of  the  urethra,  and  not  infrequently  in  the  bladder.  Separat- 
ing the  labia  with  the  fingers  the  meatus  appears  red  and  swollen,  and 
from  the  urethra  there  may  be  expressed  a  drop  or  more  of  pus.  In 
three  or  four  weeks  the  urethra  usually  appears  normal,  though  a  drop 
of  pus  can  sometimes  be  expressed  by  stripping  the  urethra.    In  a  small 


Fig.  352 


Expressing  a  drop  of  pus  from  the  urethra. 


proportion  of  cases  the  lesion  passes  into  a  chronic  stage,  in  which 
the  urethra  becomes  firm  from  thickening.  Through  the  endoscope 
part  or  all  of  the  urethra  appears  swollen,  having  little  or  no  secretion. 
Strictures  are  seldom  formed.  Exacerbations,  with  all  the  usual 
manifestations  of  a  recent  acute  infection,  are  the  rule.  These  exacer- 
bations can  usually  be  explained  by  the  presence  of  gonococci  in  the 
crypts  near  the  meatus.  From  these  crypts  pus,  which  contains 
gonococci,  can  often  be  expressed  in  the  absence  of  an  apparent  lesion 
elsewhere  in  the  urethra.  The  severity  of  the  symptoms  of  urethritis 
does  not  depend  so  much  upon  the  acuteness  of  the  lesion  as  upon 
the  location.  The  farther  the  infection  extends  into  the  urethra,  the 
more  intense  the  suffering.  A  posterior  urethritis  gives  rise  to  symp- 
toms resembling  cystitis.     The  desire  for  urination  is  frequent  and 


524  GONORRHEA  IN  WOMEN 

painful,  sometimes  amounting  to  tenesmus.  Urination  is  difficult,  and 
sometimes  it  is  impossible  to  void  the  urine,  thereby  necessitating  the 
use  of  the  catheter.  The  desire  for  urination  may  be  great,  even  when 
there,  is  but  little  urine  in  the  bladder.  This  desire  may  be  experienced 
only  at  night  or  may  be  worse  when  the  patient  is  on  her  feet.  Such 
are  the  most  severe  types.  In  the  majority  of  chronic  cases  there  is 
no  great  pain  on  urinating. 

Gonorrheal  Cystitis. — When  a  patient  complains  of  a  persistent 
frequency  of  urination  associated  with  pain  in  the  bladder,  two  things 
are  required  of  the  physician:  (1)  A  microscopic  examination  of  the 
urine  obtained  by  means  of  the  catheter,  in  view  of  finding  pus  cells 
and  the  gonococcus;  (2)  a  cystoscopic  examination,  to  determine  the 
location  and  extent  of  the  infection. 

The  gonococcus  plays  a  minor  role  in  the  causation  of  cystitis.  The 
germ  is  usually  far  outnumbered  by  other  microorganisms — the 
colon  bacillus,  streptococcus,  and  proteus  of  Hauser.  When  the  gono- 
coccus is  the  initial  cause  of  the  infection  it  usually  gives  way  to  the 
above-mentioned  microbes.  Young,  however,  has  found  a  pure  culture  of 
the  gonococcus  in  cystitis  of  five  years'  standing.  While  the  gonococcus 
has  been  found  in  the  pelvis  of  the  kidney  and  in  the  cortex  of  the 
kidney,  the  question  is  still  under  dispute  as  to  whether  the  infection 
of  the  kidney  is  due  to  direct  extension  from  the  bladder  and  ureters 
or  is  conveyed  by  w^ay  of  the  blood  current.  The  weight  of  evidence 
is  in  favor  of  direct  extension.  As  with  the  bladder  so  with  the  kidney, 
the  gonococcus  is  usually  associated  with  the  colon  bacillus  and  other 
microorganisms. 

Gonorrheal  vulvitis  is  often  seen  in  childhood,  but  is  rare  in  advanced 
years.  It  seldom  exists  in  the  chronic  stage  because  of  the  rapidity 
w4th  which  healing  takes  place.  As  a  rule,  the  vulva  is  primarily 
infected  in  infants,  but  in  adults  it  is  generally  secondary  to  a  uterine 
infection. 

In  acute  gonorrheal  vulvitis  the  tissues  are  deeply  congested  and 
the  surface  is  covered  with  pus  or  a  pseudodiphtheric  membrane. 
Underneath  the  secretion  superficial  or  deep  ulcers  may  form;  they 
are  sensitive  and  bleed  to  the  touch.  The  pus  accumulates  in  the  fossa 
navicularis.  The  hymen  is  swollen  and  red.  Eczema  of  the  labia  and 
neighboring  skin  arises  from  lack  of  cleanliness.  The  vulvar  glands 
may  be  infected  and  transformed  into  numerous  small  abscesses  con- 
taining gonococci.  Associated  with  these  changes  are  sensations  of 
heat  and  burning  about  the  external  genitals,  burning  on  urinating, 
and  embarrassment  in  Avalking  and  sitting.  These  subjective  symptoms 
usually  disappear  in  three  to  five  days,  and  within  two  weeks  little  or 
no  trace  of  the  lesion  remains.  Healing  is  slower  in  childhood  and 
in  old  age. 

Gonorrheal  bartholinitis  may  be  in  evidence  as  early  as  the  second 
week  of  the  infection,  but,  as  a  rule,  these  glands  are  not  involved  for 
weeks  and  months  following  the  initial  infection.  The  mouths  of  the 
glands  become  red  and  swollen.     Here  the  process  may  be  checked  or 


DIAGNOSIS 


525 


the  glands  may  enlarge  into  a  round  or  spindle-shaped  body,  varying 
in  size  from  a  hazel-nut  to  a  hen's  egg.  They  are  tender,  and  may 
fluctuate.  Both  glands  are  commonly  involved,  though  not  to  the 
same  degree. 

Gonorrheal  vaginitis  is  rarely  if  ever  seen  in  the  chronic  stage.  In 
the  acute  stage  it  is  occasionally  seen  in  infancy  and  old  age  as  a  primary 
lesion,  but  in  the  period  of  sexual  maturity  it  is  invariably  secondary 
to  a  uterine  infection.  The  finding  of  the  gonococcus  in  the  vagina 
is  not  evidence  of  gonorrheal  vaginitis.  The  gonococci  may  lie  in  the 
vaginal  secretions  without  attacking  the  vaginal  tissues.  In  the  acute 
stage  the  temperature  may  be  elevated,  there  is  a  burning  sensation 
in  the  vagina,  physical  exertion  causes  distress,  and  to  the  examining 

Fig.  353 


Palpation  of  the  vulvovaginal  gland. 


finger  the  vagina  is  hot  and  tender.  The  surface  is  red  and  swollen, 
and  in  virulent  cases  erosions  and  ulcers  may  develop  beneath  the 
purulent  secretion  which  bathes  the  surface.  The  disease  is  usually 
self-healing  within  a  few  weeks. 

Gonorrheal  metritis  exists  in  both  the  acute  and  chronic  stages.  The 
infection  may  be  confined  to  the  cervix  or  may  invade  the  uterine 
body.  It  is  not  invariably  confined  to  the  mucosa,  as  was  formerly 
believed,  but  may  invade  the  musculature  throughout  its  entire  extent. 

In  the  acide  stage  the  cervix  is  red,  swollen,  sensitive  to  pressure, 
and  may  bleed  on  handling.  A  mucopurulent  secretion  extrudes  from 
the  cervical  canal,  and  in  this  secretion  the  gonococcus  is  found  in  large 
numbers  throughout  the  acute  stage.  So  long  as  the  infection  is 
confined  to  the  cervix  there  may  be  an  absence  of  all  symptoms.    With 


526  GONORRHEA  IN  WOMEN 

the  invasion  of  the  uterine  body  the  temperature  usually  rises  a  degree 
or  more,  there  is  pain  and  tenderness  in  the  hypogastrium  and  urina- 
tion is  frequent  and  painful.  As  a  rule,  the  symptoms  rapidly  subside, 
with  the  exception  of  a  profuse  leucorrhea,  which  commonly  persists 
indefinitely.  On  bimanual  examination  the  uterus  is  tender  to  pressure 
and  is  slightly  enlarged. 

Chronic  gonorrheal  metritis  may  be  so  varied  and  so  obscure  in  its 
clinical  manifestations  that  the  true  nature  of  the  infection,  and  even 
the  existence  of  an  infection,  might  be  overlooked  without  a  systematic 
bacteriological  examination.  All  the  usual  symptoms  may  be  wanting. 
A  careful  examination  of  the  uterus  may  reveal  no  change  in  its  size, 
mobility,  and  consistency.  There  may  be  no  undue  sensitiveness  and 
an  absence  of  a  visible  secretion,  yet  the  gonococci  may  be  found 
in  the  transparent,  viscid  secretion  of  the  cervix.  Erosions  are  often 
seen  on  the  cervix,  and  the  entire  uterus  may  be  enlarged,  firm  in 
consistency,  and  somewhat  tender  to  pressure.  Exacerbations  of  pain, 
tenderness,  and  a  purulent  leucorrhea  are  suggestive  of  gonorrheal 
infection. 

There  is  nothing  in  the  macroscopic  or  microscopic  appearances  of 
the  tissues  of  the  uterus  that  will  characterize  a  gonorrheal  infection. 
The  tissue  changes  are  identical  with  those  of  puerperal  infection.  On 
the  vaginal  portion  of  the  cervix  are  erosions  of  the  papillary,  glandular, 
and  follicular  varieties.  In  the  cervix  and  body  of  the  uterus  the 
macroscopic  appearances  are  those  of  endometritis  of  the  hypertrophic, 
polypoid,  or  fungous  types,  which  under  the  microscope  present  the 
usual  picture  of  glandular  or  interstitial  endometritis.  It  is  only  by 
the  detection  of  the  gonococcus  in  the  tissues  that  the  diagnosis  can  be 
made  with  certainty. 

Gonorrheal  salpingitis  is  always  secondary  to  an  infection  of  the 
uterus.  It  is  exceptional  for  the  infection  to  be  conveyed  to  the  tubes 
early  in  the  history  of  the  infection.  While  the  tubes  have  been  invaded 
within  ten  to  fourteen  days  of  the  initial  infection  in  the  cervix,  the 
rule  is  that  they  are  not  attacked  for  months  and  possibly  years.  A 
guarded  prognosis,  therefore,  should  always  be  given  in  regard  to  the 
involvement  of  the  tubes  while  the  infection  is  confined  to  the  uterus, 
as  it  is  not  known  when  the  infection  may  extend  to  the  tubes. 

The  Predisposing  Causes  of  Extension  to  the  Tubes  are:  1.  Untimely 
intra-uterine  manipulations  in  the  infected  uterus  by  means  of  the 
sound  or  curet. 

2.  Exposure  and  exertion  during  the  men^strual  period. 

3.  Labor  and  abortion,  causing  an  extension  of  a  latent  infection  in 
the  uterus  to  the  tubes.  Women  who  are  the  carriers  of  a  latent 
infection  in  the  uterus  should  not  become  pregnant. 

Gonorrheal  salpingitis  is  usually  ushered  in  by  a  chill,  followed  by 
a  rise  in  temperature  of  1°  to  4°  F.,  together  with  the  development 
of  pain  and  tenderness  in  the  sides  of  the  pelvis.  In  event  of  menstrua- 
tion, the  periods  are  prolonged  and  painful,  with  exaggerated  local  and 
general  disturbances. 


PROGNOSIS  527 

Without  an  anesthetic  it  is  impossible  to  outhne  the  infected  tubes 
because  of  the  extreme  tenderness.  In  the  early  stages  the  tubes  are 
but  slightly  enlarged  and  are  not  readily  palpated.  As  the  disease 
develops  the  tubes  may  be  palpated  as  an  irregular,  elongated  structure, 
extending  from  the  cornua  of  the  uterus  to  the  sides  of  the  pelvis  or 
lying  closely  adherent  to  the  sides  or  posterior  surface  of  the  uterus. 
They  are  tender  to  pressure,  and  are,  as  a  rule,  more  or  less  fixed 
by  adhesions.  It  may  or  may  not  be  possible  to  detect  fluctuation. 
In  the  subacute  and  chronic  stages  exacerbations  of  fever,  pain 
and  tenderness  are  occasionally  experienced.  These  are  prone  to 
occur  at  the  menstrual  periods  and  to  follow  undue  exertion.  Bladder 
and  rectal  disturbances  are  often  included  in  the  clinical  syndrome, 
and  are  due  either  to  infection  of  these  structures  or  to  pressure  by 
the  tender  and  enlarged  tubes. 

Gonorrheal  ovaritis  is  the  result  of  extension  of  the  infection  from 
the  tubes  to  the  ovaries,  and  does  not  exist  independent  of  salpingitis. 
The  clinical  manifestations  are  identical  with  salpingitis. 

All  the  inflammatory  lesions  common  to  the  ovary  are  observed. 
Adhesions  form  about  the  ovary,  binding  it  to  the  tube  and  surrounding 
structures.  Newly  formed  connective  tissue  may  develop  in  the  sub- 
stance of  the  ovary  and  lead  to  cystic  degeneration.  These  changes 
in  and  about  the  organ  are  fruitful  sources  of  sterility.  In  addition 
to  these  pathological  conditions,  abscesses  of  the  ovary  are  not  infre- 
quently developed. 

Gonorrheal  peritonitis. — -(See  page  501.) 

Gonorrhea  of  the  rectum  occurs  in  about  8  per  cent,  of  all  gonorrheal 
infections  of  the  genital  tract.  The  lesion  is  commonly  overlooked. 
The  contributing  causes  are  coitus  per  anum,  digital  and  instrumental 
examinations  in  the  presence  of  gonorrheal  infection  of  the  genital 
tract,  and  lack  of  cleanliness  in  the  presence  of  leucorrheal  discharges 
of  a  gonorrheal  nature.  Caution  should  be  exercised  in  giving  enemata 
for  fear  of  conveying  an  infective  vaginal  discharge  to  the  rectum. 
When  a  patient,  who  is  the  carrier  of  a  gonorrheal  infection,  complains 
of  discomfort  in  the  rectum,  an  effort  should  be  made  to  discover  the 
gonococcus.     Only  by  this  means  is  the  disease  recognized. 

Prognosis. — Inasmuch  as  one  cannot  foretell  the  ultimate  outcome 
of  a  gonorrheal  infection,  a  guarded  prognosis  should  always  be  given. 
The  infection  may  be  of  low  virulence  and  confined  to  a  limited  area. 
Such  an  infection  may  exist  without  recognition,  but  it  may  persist 
for  an  indefinite  time  and  be  transferred  to  a  second  individual,  and 
then  give  rise  to  a  virulent  infection.  Again,  such  a  latent  infection 
confined  to  the  lower  genito-urinary  tract  may  ultimately  spread  to 
the  upper  genital  tract,  and  with  disastrous  results. 

Gonorrhea  in  Relation  to  Sterility. —  A  large  proportion  of  sterile 
marriages  are  due  to  gonorrhea.  Bumm  estimates  that  30  per  cent, 
of  women  infected  with  gonorrhea  are  sterile.  IMore  than  half  of  the 
women  who  have  married  men  known  to  have  had  gonorrhea  are  sterile 
(Noeggerath) .  This  statement  is  probably  an  exaggeration.  Fully 
70  per  cent,  of  sterile  marriages  are  chargeable  to  gonorrhea,  either  in 


528  GONORRHEA  IN  WOMEN 

the  husband  or  in  the  wife,  or  in  both.  Sterihty  is  chargeable  to  the 
husband  in  70  per  cent,  of  cases  according  to  the  statement  of  Vedeler, 
in  50  per  cent,  according  to  Olshausen,  and  in  34  per  cent,  according 
to  Chrobak.  These  figures  refer  not  only  to  the  percentage  of  sterility 
in  the  male,  but  to  his  part  in  rendering  the  wife  sterile. 

The  so-called  "one-child  sterility"  is  accounted  for  in  large  measure 
by  the  extension  of  a  preexisting  gonorrheal  infection  during  the 
puerperium,  for  it  i:^  a  long-established  fact  that  in  the  puerperium 
the  infection,  which  was  confined  to  the  cervix  and  urethra,  is  prone 
to  extend  to  the  corpus  and  tubes,  and  will  then  almost  certainly  result 
in  sterility. 

Influence  of  Gonorrhea  on  Pregnancy. — Gonorrhea  is  not  necessarily 
a  barrier  to  conception.  In  a  number  of  the  Continental  hospitals  it 
was  found  that  20  to  25  per  cent,  of  pregnant  women  were  infected. 
In  them  the  infection  was  usually  confined  to  the  cervix  and  urethra, 
though  it  is  well  known  that  the  body  of  the  uterus  and  the  appendages 
may  be  infected  and  not  preclude  the  possibility  of  pregnancy. 

Influence  of  Gonorrhea  upon  the  Termination  of  Pregnancy. — Gonor- 
rhea is  a  potent  factor  in  the  causation  of  abortions.  Sanger  estimates 
the  abortive  influence  of  gonorrhea  to  be  as  great  as  that  of  syphilis. 
It  is  estimated  that  20  to  30  per  cent,  of  women  who  are  infected  with 
gonorrhea  fail  to  carry  their  children  to  full  term. 

One  case  in  six  of  puerperal  sepsis  is  caused  by  gonorrhea.  Of  this 
number  but  few  are  the  result  of  contamination  in  labor  and  the  puer- 
perium. The  majority  are  due  to  preexisting  infections  in  the  genital 
tract,  which  are  awakened  to  renewed  activity  and  caused  to  extend; 
a  gonorrheal  cervicitis  extends  to  the  body  of  the  uterus  and  thence 
to  the  appendages;  a  latent  infection  in  the  appendages  spreads  to 
the  peritoneum;  thus  it  happens  that  an  infection  which  may  have 
been  previously  unrecognized  becomes  a  serious  menace  to  life  and  a 
barrier  to  conception. 

Risks  to  the  Offspring. — In  the  passage  of  the  child  through  the 
cervix  and  vagina  of  an  infected  mother,  there  is  great  liability  to 
contamination  of  the  conjunctiva.  It  is  estimated  that  from  10  to  30 
per  cent,  of  the  cases  of  blindness  in  the  world  are  due  to  gonorrhea. 
According  to  Xeisser  there  are  now  in  Germany  30,000  blind  persons 
whose  loss  of  sight  may  be  thus  accounted  for.  Happily,  the  frequency 
of  this  accident  is  being  materially  reduced  by  antiseptic  vaginal 
douches  given  prior  to  the  delivery  of  gonorrheal  cases  and  by  the 
employment  of  the  Crede  method  of  treatment  of  the  eyes  of  the  newborn. 

Location  of  the  Infection. — The  prognosis  is  largely  influenced  by 
the  location  of  the  infection,  von  Winckel  presents  the  following 
statistics  relative  to  the  localization  of  gonorrhea: 

Urethra,  acute  and  chronic G2.0  to  85  per  cent. 

Cervix 47.0  to  72  per  cent. 

Uterus 14.0  to  .50  per  cent. 

Vagina 2-3.0  to  40  per  cent. 

Bartholin's  glands .36  per  cent. 

Vulva 12.0  to  2.5  per  cent. 

Tube 3.6  to  33  per  cent. 


TREATMENT  OF  ACUTE  STAGE  '  529 

Bumm  made  observations  in  55  cases  and  found: 
50  (90.0  per  cent.)  with  gonorrheal  urethritis. 
41  (74.0  per  cent.)  with  gonorrheal  cervicitis. 
8  (14.0  per  cent.)  with  gonorrheal  endometritis. 
2  (  3.6  per  cent.)  with  gonorrheal  salpingitis. 
Prophylaxis. — The  prevention   of  gonorrhea   is   a  problem   of   vast 
importance  because  of  the  direful  results  of  the  infection  and  the 
uncertainty  of  cure.     Following  are  essential  features  of  prophylaxis: 

1.  The  public  should  be  impressed  with  the  prevalence  and  serious 
consequences  of  the  disease. 

2.  The  physician  should  not  pronounce  a  cure  or  gWe  sanction  to 
marriage  or  to  the  resumption  of  the  marital  relation  until  repeated 
microscopic  examinations  demonstrate  the  absence  of  the  gonococcus 
in  the  secretions. 

3.  Medical  regulation  and  supervision  of  prostitution  does  not 
protect  but  rather  promotes  a  false  sense  of  security. 

4.  So  long  as  a  woman  is  the  carrier  of  gonococci,  she  should  avoid 
becoming  pregnant  in  the  interest  of  both  herself  and  child.  The 
possible  extension  of  the  infection  in  the  mother  and  the  development 
of  ophthalmia  in  the  newborn  justify  the  precaution. 

Active  Treatment. — Before  deciding  upon  a  course  of  treatment  it 
is  well  to  consider  the  social,  economic,  and  moral  influences  which 
affect  the  individual.  When  the  woman  is  able  to  take  reasonable 
care  of  herself,  and  when  her  moral  life  would  favor  recovery,  con- 
servative treatment  may  be  looked  upon  with  favor;  but  when  for 
financial  and  domestic  reasons  a  long  period  of  treatment  and  invalidism 
could  not  be  wisely  pursued  and  when  the  moral  status  of  the  individual 
will  forestall  all  efforts  toward  recovery,  conservative  treatment  will 
fail.  Such  women  should  be  rid  of  their  troubles  in  the  shortest  possible 
time,  and  to  this  end  operative  procedures  are  favored.  "Thus  immoral 
individuals  would  be  made  less  a  menace  to  the  community,  less  a  burden 
upon  our  hospitals,  and  the  wage-earner  would  be  more  quickly  fitted 
for  pursuing  her  daily  task." 

Treatment  of  Acute  Stage. — The  most  essential  factor  in  the  manage- 
ment of  gonorrhea  in  the  acute  stage  is  rest.  The  patient  should  be 
confined  to  bed  and  all  instrumental  and  digital  manipulations  inter- 
dicted for  fear  of  spreading  the  infection. 

Cleanliness  is  second  in  importance  to  rest.  Antiseptic  vaginal 
douches  should  be  given  for  the  purpose  of  keeping  the  vagina  free  of 
the  leucorrheal  discharges.  Lysol,  creolin,  or  bichloride  douches  are 
preferred.  These  douches  should  be  given  in  the  recumbent  position, 
they  should  be  at  a  temperature  of  110°  to  112°  F.,  and  should  be 
given  for  ten  to  twenty  minutes.  The  author's  preference  is  for  mer- 
curic chloride  (1  to  2000).  In  addition  to  the  cleansing  qualities  of 
the  douche  the  pelvic  tissues  are  depleted,  and  in  this  manner  the  active 
stage  of  the  infection  is  shortened.  When  pain  and  tenderness  are 
referred  to  the  pelvis  an  ice-bag  should  be  applied  to  the  lower  abdominal 
region.  For  relief  from  pain,  aspirin,  heroin,  morphine,  and  hyoscyamus 
34 


530  GONORRHEA  IN  WOMEN 

may  be  resorted  to  when  rest  and  the  application  of  the  ice-bag  fail 
to  give  relief.     The  diet  should  be  free  from  stimulants  and  spices. 

Under  no  circumstances  is  the  uterine  cavity  or  the  cervical  canal 
to  be  invaded  in  the  acute  stage  with  injections  or  with  swabs  for  fear 
of  extending  the  infection. 

Surgery  has  no  place  in  the  treatment  of  acute  gonorrhea,  with  the 
possible  exception  of  vaginal  drainage  in  event  of  an  accumulation  of 
pus  in  the  pelvis,  an  occasion  which  will  rarely  arise  in  the  early  stage 
of  the  infection.  In  acute  infection  of  the  urethra  and  bladder  all  injec- 
tions should  be  proscribed.  Large  quantities  of  water  and  milk  should 
be  drunk  for  the  purpose  of  cleansing  the  urinary  tract.  Urotropin 
in  0.45  to  0.65  gm.  (7  grains  to  10  grains)  doses,  given  three  or  four 
times  a  day,  is  said  to  have  an  antiseptic  action,  and  is  in  general  use. 

Treatment  of  the  Subaxute  and  Chronic  Stages. — Local  measures  may 
be  instituted  in  from  four  to  six  weeks  from  the  beginning  of  the  infec- 
tion, depending  upon  the  virulence  and  extent  of  the  infection. 

Treatment  of  Subacute  and  Chronic  Urethritis. — When  there  is  distress 
from  burning  pain  on  urinating,  the  balsam  of  copaiba  will  afford  much 
relief.  Jadassohn  recommends  orgonin  in  a  1  to  2  per  cent,  solution, 
and  speaks  highly  of  its  effectiveness  and  of  its  non-irritating  qualities. 

Pardoe  recommends  a  2  to  4  per  cent,  solution  of  silver  nitrate  solu- 
tion as  a  prophylactic  remedy.  The  application  is  made  in  the  first 
twenty-four  to  forty-eight  hours  of  the  infection.  In  cases  of  long-stand- 
ing he  irrigates  the  urethra  with  permanganate  of  potassium.  Pollard 
speaks  favorably  of  protargol  (5  to  10  per  cent,  solution)  as  a  prophyl- 
actic remedy.  Bierhoff  injects  into  the  bladder  150  c.c.  of  a  0.25  to  0.5 
per  cent,  protargol  solution.  The  solution  is  permitted  to  remain  in 
the  bladder  until  voided.  Boldt  introduces  into  the  urethra  a  pledget 
of  absorbent  cotton  saturated  with  a  10  per  cent,  solution  of  protargol. 
This  application  is  left  for  fifteen  minutes,  when  the  cotton  is  removed. 
Bentler  injects  a  solution  of  potassium  permanganate  (1  to  5000) ; 
this  is  voided  and  is  followed  by  an  injection  into  the  bladder  of  a  silver 
nitrate  solution  (1  to  1000). 

When  the  acute  stage  has  passed  into  the  subacute  and  chronic 
stages,  oleum  santale  or  balsam  of  copaiba  should  be  administered. 
The  latter  may  be  given  in  capsules  of  15  grains  each,  three  times 
daily.  When  there  is  pain  on  urination,  archovin  is  said  to  afford 
much  relief.  This  remedy  produces  an  acid  urine  and  has  a  sedative 
effect  upon  the  mucosa  of  the  urethra;  24  to  48  grains  may  be  given 
daily  in  divided  doses  of  4  to  6  grains  each.  Gonosan  is  80  per  cent, 
sandalwood  oil  and  20  per  cent,  kava,  soluble  in  ether,  alcohol,  or 
chloroform.  Its  effect  upon  the  mucosa  is  to  reduce  the  hyperemia 
and  to  anesthetize  the  sensitive  surfaces,  thereby  relieving  pain  and 
diminishing  the  secretions. 

That  no  one  remedy  has  proved  eminently  satisfactory  is  evident 
from  the  large  number  of  remedies  advised,  and  the  hopelessly  divergent 
views  of  experts  as  to  their  proper  application.  In  the  chronic  stage 
of  gonorrheal  urethritis  the  lesions  are  localized  in  one  or  more  areas, 


TREATMENT  OF  SUBACUTE  AND  CHRONIC  VULVOVAGINITIS     531 

and  should  be  treated  with  strong  astringents  and  antiseptics,  or  by 
the  cautery,  through  an  endoscope.  For  this  purpose  a  20  per  cent, 
to  50  per  cent,  silver  nitrate  solution  may  be  employed,  the  applications 
being  made  with  an  applicator  introduced  through  an  endoscope. 

Kelly  advises  the  introduction  of  an  endoscope  to,  but  not  beyond, 
the  sphincter,  and  as  it  is  slowly  withdrawn  the  mucosa  which  folds 
into  view  is  swabbed  with  a  5  per  cent,  silver  nitrate  solution.  To 
lessen  the  pain  the  urethra  may  be  first  swabbed  with  a  10  per  cent, 
solution  of  the  hydrochlorate  of  cocaine.  This  may  be  done  through 
an  endoscope  in  the  manner  described  above. 

Special  attention  is  to  be  given  the  orifices  of  Skene's  glands  when 
infected.  Through  a  large,  blunt  hypodermic  needle  a  10  per  cent, 
silver  nitrate  solution  is  injected  into  the  lumen  of  the  gland.  In 
obstinate  cases  the  gland  should  be  incised  throughout  its  entire  length 
(one-half  inch)  by  passing  a  fine  probe  into  the  gland  and  cutting  down 
upon  it.  The  exposed  gland  is  then  cauterized  with  a  10  per  cent, 
solution  of  silver  nitrate.  The  glands  of  Bartholin  are  treated  in  a 
similar  manner. 

The  efficacy  of  gonococcic  serums  in  the  treatment  of  gonorrheal 
urethritis  is  as  yet  debatable.  Perez-Miro  has  given  intramuscular 
injections  of  gonococcic  serum,  and  has  observed  an  initial  increase  in 
the  secretions,  which  is  later  followed  by  a  gradual  decrease.  Herbst, 
on  the  other  hand,  has  had  no  favorable  results  from  such  injections 
in  the  acute  stage,  and  doubtful  results  in  subacute  and  chronic  cases. 
In  contradiction  to  the  findings  of  Herbst,  Aronstam  obtained  positive 
results  in  acute  cases  and  negative  results  in  chronic  cases. 

Treatment  of  Subacute  and  Chronic  Vulvovaginitis. — I"n  the  treatment 
of  gonorrheal  vaginitis  the  method  in  general  practice  consists  in  inject- 
ing a  1  to  10  per  cent,  solution  of  silver  nitrate  into  the  vagina,  at 
intervals  of  two  or  three  days.  In  infants  this  is  best  done  by  means 
of  a  catheter,  and  in  adults,  when  ulcers  exist,  the  cautery  may  be 
used  to  advantage,  and  to  prevent  cicatrization  of  the  vaginal  walls 
the  vagina  should  be  packed  with  iodoform  gauze. 

While  nitrate  of  silver  is  unquestionably  the  most  effective  agency 
it  may  be  very  distressing.  A  good  substitute,  though  not  so  effective, 
is  protargol  in  a  10  per  cent,  to  20  per  cent,  solution.  One  or  more 
daily  vaginal  douches  of  formalin  (1  to  4000)  or  bichloride  of  mercury 
(1  to  2000)  may  be  effectively  applied. 

In  stubborn  cases  iodoform  powder  or  aristol  may  be  applied  two  or 
three  times  a  week  by  dusting  the  powder  thickly  upon  non-absorbent 
cotton  or  gauze,  and  tightly  packing  the  vagina.  These  packs  are 
removed  in  twenty-four  to  thirty-six  hours,  and  are  followed  by  for- 
malin douches.  All  infected  follicles  should  be  incised  and  disinfected 
with  pure  formalin  or  burned  with  a  galvanocautery. 

In  the  management  of  acute  vulvitis  a  weak  solution  of  bichloride 
of  mercury  (1  to  1000  to  1  to  5000)  should  be  used  freely  as  a  douche. 
Cotton  may  be  saturated  with  a  similar  solution  and  applied  several 
times  a.  day.  The  patient  should  be  confined  to  bed  and  laxatives 
administered  as  required. 


532  GONORRHEA  IX  WOMEN 

When  the  BarihoJinean  cilanch  are  infected  the  most  effective  cure 
is  found  in  the  eradication  of  the  gLand.  If  this  can  be  accompHshed 
without  rupturino;  the  infected  gland  the  wound  can  be  closed  with 
buried  layers  of  catgut.  ^Yhen  the  wound  is  contaminated  by  the  escape 
of  pus  the  ca^•ity  should  be  lightly  packed  with  iodoform  gauze  and 
allowed  to  heal  by  granulations.  (For  the  treatment  of  vulvovaginitis 
in  infants  see  page  53(1) 

Uterus. — Acute  Stage. — Whether  the  infection  is  due  to  the  gono- 
coccus  alone  or  to  a  combination  of  the  gonococcus  with  the  strepto- 
coccus, staphylococcus,  or  colon  bacillus,  non-interference  should  be 
enjoined  through  the  acute  stage  of  the  infection.  All  intra-uterine 
manipulations  are  proscribed  for  fear  of  extending  the  infection  to 
the  tubes  and  of  introducing  a  secondary  infection.  An  indispensable 
factor  in  the  treatment  of  these  cases  is  rest,  and  to  this  end  such  cases 
are  best  treated  in  the  hospital  or  at  home  under  the  care  of  a  trained 
nurse. 

Antiseptic  ^•aginal  douches  will  serve  a  useful  purpose  in  maintaining 
cleanliness.  The  vaginal  walls  and  vulva  may  become  infected  from 
the  uterine  secretions,  and  to  avoid  this,  antiseptic  ^•aginal  douches 
should  be  given  every  four  to  eight  hours.  These  douches  may  be  of 
bichloride  of  mercury  ,(1  to  2000)  or  formahn,  1  dram  toj:  quarts  of 
hot  sterile  water. 

When  all  fever  has  subsided  the  douches  should  be  given  over  a  period 
of  fifteen  to  twenty  minutes  and  repeated  four  times  a  day.  The  vagina 
should  be  loosely  packed  with  sterile  absorbent  cotton  or  gauze  tampons 
soaked  in  a  7  per  cent,  ichthyol  glycerin  solution.  These  packs  should 
be  given  e^•e^y  da\'  or  every  other  day.  Six  to  eight  hours  is  the  usual 
period  for  the  application  of  the  packs.  They  should  be  preceded  and 
followed  by  hot,  antiseptic,  vaginal  douches. 

No  intra-uterine  applications  should  be  made  until  all  signs  of  acute 
inflammation  have  passed.  This  period  may  be  arbitrarily  fixed  at 
three  weeks. 

In  the  acute  stage,  sitz  baths  at  a  temperature  of  70°  F.  may  be 
given  for  a  short  period.  An  ice-bag  should  be  placed  over  the  hypo- 
gastrium  and  hot  vaginal,  bichloride  douches  should  be  given  at  low 
pressure. 

Subacute  and  Chronic  Stages. — After  the  acute  stage  has  passed 
vaginal  douches  and  glycerin-ichthyol  tampons  are  to  be  supplemented 
by  topical  applications  to  the  infected  endometrium. 

The  author's  preference  is  for  a  30  to  50  per  cent,  zinc  chloride 
solution.  A  general  anesthetic  is  given  and  the  cervix  dilated.  A  30 
to  50  per  cent,  solution  of  zinc  chloride  is  swabbed  over  the  infected  sur- 
face. This  acts  as  an  escharotic  in  destroying  the  superficialh\infected 
tissues,  and  has  the  advantage  over  the  curet  in  not  creating  a  wound. 
After  an  interval  of  ten  days  a  5  per  cent,  solution  of  zinc  chloride 
should  be  injected  through  the  cervix  into  the  cavity  of  the  uterus. 
But  two  or  three  drops  of  the  solution  should  be  injected.  These  treat- 
ments are  repeated  at  intervals  of  ten  to  fourteen  days.     Not  more 


UTERUS 


533 


than  six  to  eight  injections  should  be  made  for  fear  of  too  great 
destruction  of  tissues. 

To  inject  this  fluid,  the  author  uses  a  solid  piston  tonsillar  syringe, 
with  a  long  curved  cannula  of  a  caliber  that  will  permit  of  easy  mtro- 
duction  through  the  cervical  canal  without  dilatation.  Xo  anesthetic 
is  required. 

The  curet  should  never  be  used  in  the  presence  of  a  purulent 
leucorrhea,  except  for  the  control  of  hemorrhage. 

Fig.  354 


Injection  of  the  urethra.     Labia  held  apart  by  the  left  hand. 


Throughout  the  course  of  the  treatment  bacteriological  examinations 
of  the  cervical  secretions  should  be  made  from  time  to  time.  By  so 
doing  one  can  judge  of  the  progress  of  the  case.  A  cure  is  pronounced 
only  when  repeated  bacteriological  tests  give  negative  results. 

When  erosions  of  the  cervix  exist,  these  erosions  should  be  painted 
with  a  10  to  20  per  cent,  solution  of  silver  nitrate  or  with  a  10  to  20 
per  cent,  solution  of  zinc  chloride.  These  applications  may  be  repeated 
once  or  twice  a  week.  When  there  is  a  deep-seated  infection  of  the 
vaginal  portion  of  the  cervix  the  most  effective  means  of  treatment  is 
the  amputation  of  the  cervix. 

Hysterectomy  is  advised  when  the  uterus  and  its  appendages  are 
together   involved.      It   is   only   when    more    conservative,    tentative 


534  GONORRHEA  IN  WOMEN 

measures  have  been  given  a  full  trial  and  have  failed  to  give  relief 
that  such  heroic  measures  should  be  adopted. 

Fallopian  Tubes. — Acute  Stage. — During  the  acute  stage  the  treatment 
is  that  of  acute  pelvic  inflammation  in  general.  During  this  period 
unnecessary  examinations  and  manipulations  are  prohibited  for  fear 
of  stripping  the  pus  contents  of  the  tubes  into  the  pelvic  cavity.  In 
addition  to  rest,  measures  for  the  relief  of  pain  and  the  depletion  of 
the  congested  tissues,  such  as  vaginal  hot  douches,  glycerin  tampons, 
and  ice  packs  to  the  lower  abdomen,  are  to  be  employed. 

Chronic  Stage. — Palliative  treatment  will  forestall  operative  inter- 
vention in  a  large  proportion  of  cases.  The  application  of  long-continued 
hot  vaginal  douches,  of  ichthyol  and  glycerin  tampons,  the  regulation 
the  bowels,  and  the  avoidance  of  excessive  exercise  will  often  serve  of 
to  keep  the  patient  in  a  fairly  comfortable  condition. 

When  the  tubal  infection  continues  to  cause  serious  disturbances,  and 
at  intervals  of  weeks  and  months  is  awakened  to  acute  exacerbations, 
operative  measures  should  be  resorted  to.  The  removal  of  the  tubes 
alone  seldom  results  in  complete  relief.  Nothing  short  of  the  complete 
extirpation  of  the  uterus  and  infected  tubes  will  promise  an  ultimate 
cure  in  a  large  proportion  of  cases.  When  possible  the  ovaries  or  a 
portion  of  them  should  be  saved.  The  choice  between  a  vaginal  or 
an  abdominal  operation  depends  upon  the  extent  of  the  adhesions. 
Vaginal  drainage  should  be  done  when  the  tubes  are  distended  with 
pus  and  can  be  readily  reached  per  vaginam.  For  further  discussion 
of  the  operative  technic  of  inflammatory  diseases  of  the  tubes  and 
ovaries  see  respective  chapters. 

Ovaries. — Acute  Stage. — The  management  of  acute  ovaritis  does 
not  differ  from  that  of  acute  metritis. 

Chronic  Stage. — The  utmost  conservatism  should  be  exercised  in 
the  management  of  infected  ovaries.  The  author  questions,  if  in  a 
young  woman,  it  is  ever  necessary  to  remove  all  of  both  ovaries. 
Even  when  both  ovaries  are  the  seat  of  abscess  formation,  it  is  almost 
always  possible  to  leave  a  portion  of  the  abscess  wall.  All  means  should 
be  used  to  conserve  the  ovaries.  When  these  measures  fail  to  give  the 
desired  relief,  when  the  patient  persists  in  her  complaints  of  pain, 
conservative  surgery  must  be  invoked,  but  not  the  surgery  that  demands 
the  sacrifice  of  both  ovaries. 

Rectum. — ^The  infected  rectum  should  be  irrigated  with  normal  salt 
solution.  After  cleansing  it  in  this  manner  one  of  the  various  silver 
salts  should  be  injected.  For  this  purpose  20  per  cent,  protargol  or  40 
per  cent,  argyrol  solution  may  be  used.  In  stubborn  cases  a  stronger 
solution  may  be  used  as  a  swab.  Fissures  and  ulcerations  should  be 
treated  with  the  Paquelin  cautery. 

Bladder. — In  the  acute  stage  of  gonorrheal  cystitis  internal  medication 
is  of  value.  Urotropin  in  7-grain  doses  should  be  given  four  to  six  times 
a  day,  and  to  this  5  grains  of  salol  may  be  added.  Benzoic  acid  in 
10-grain  doses,  given  three  times  a  day,  will  act  as  an  antiseptic  in 
the  bladder.    The  following  prescription  is  advised  by  Bandler: 


BLADDER  535 

I^ — Extract  hyoscyam gr.  ss         0 .  037 

Salol .    gr.  V  0.325 

Urotropin gr.  v         0.325 

F.  tal.  capsulse,  no.  xx. 

Sig. — One  every  three  hours  with  water. 

For  relief  from  pain,  sitz  baths  and  hot  fomentations  are  of  value, 
but  it  may  become  necessary  to  resort  to  hypodermic  injections  of 
morphine.  A  moderate  sedative  to  the  bladder  is  found  in  a  combi- 
nation of  the  extracts  of  opium  and  hyoscyamus,  each  1  grain,  given 
as  required.  Rectal  suppositories  of  opium  and  belladonna  will  afford 
relief  from  pain. 

The  local  treatment  of  acute  cystitis  is  of  importance.  The  bladder 
should  first  be  irrigated  with  sterile  normal  salt  solution  or  a  1  per 
cent,  boracic  acid  solution.  A  non-irritating  silver  solution  should  be 
injected  into  the  bladder  immediately  following  the  irrigation.  Pro- 
targol  (1  to  500)  may  be  used  for  this  purpose.  If  the  results  are  not 
satisfactory,  a  solution  of  silver  nitrate  (1  to  5000)  may  be  injected  in 
quantities  of  2  to  6  ounces  and  allowed  to  remain  ten  or  more  minutes 
within  the  bladder.  The  strength  of  the  silver  solution  may  be  increased 
to  1  to  500  in  stubborn  cases.  Rest  in  bed  is  of  the  utmost  importance. 
An  ice-bag  may  be  applied  over  the  hypogastrium,  and  short,  cold 
vaginal  douches  given  two  to  four  times  daily.  Large  quantities  of 
milk  and  water  should  be  drunk.  A  liquid  diet,  together  with  fruits, 
is  advised.  All  red  meats,  alcoholic  beverages,  and  condiments  should 
be  avoided. 

A  long  list  of  drugs  has  been  recommended  for  the  treatment  of  acute 
cystitis,  such  as  oil  of  sandalwood,  copaiba,  and  sweet  spirits  of  nitre. 
Some  virtue  may  be  ascribed  to  them,  but  they  are  one  and  all  more 
or  less  disturbing  to  the  stomach  and  unreliable. 

In  the  chronic  stages  of  cystitis  local  applications  are  advised.  No 
drug  is  so  effective  or  in  so  general  use  as  the  nitrate  of  silver,  injected 
into  the  bladder  in  a  solution  of  1  to  2000  and  retained  for  twenty 
to  thirty  minutes  and  then  voided.  The  solution  may  be  gradually 
increased  in  strength  to  1  to  100  when  it  is  well  borne.  The  bladder 
should  be  first  irrigated  with  a  boracic  acid  solution  before  applying 
the  silver  nitrate.  It  is  not  always  possible  to  get  results  from  any 
one  line  of  treatment  conducted  for  a  considerable  time,  hence  the 
advisability  of  resorting  to  other  medicaments  when  progress  is  not 
satisfactory. 

Topical  treatments,  made  by  an  applicator  inserted  into  the  bladder 
through  an  endoscope,  will  often  accomplish  the  desired  results  when 
instillations  and  irrigations  fail.  Silver  nitrate,  in  a  10  to  20  per  cent, 
solution,  may  be  thus  applied  once  or  twice  a  week,  the  application 
being  made  direct  to  the  affected  area. 

Finally,  if  all  topical  applications  fail,  the  surgeon  may  put  the 
bladder  and  urethra  at  rest  and  establish  free  drainage  by  making 
vesicovaginal  drainage  through  an  artificial  fistula. 


536  GONORRHEA  IN  CHILDREN 


'■  GONORRHEA  IN  CHILDREN 

Etiology. — Gonorrhea  in  children  usually  arises  from  contact  with 
soiled  linen  and  sponges.  In  children's  wards  the  infection  may  be  carried 
on  thermometers  and  fingers  of  nurses,  who  go  from  one  child  to  another 
without  taking  the  precaution  to  thoroughly  cleanse  their  hands  and 
thermometers.  Children  have  been  known  to  become  infected  when 
sleeping  with  an  infected  mother  or  nurse.  Unjust  accusations  have 
been  made  through  ignorance  of  the  fact  that  gonorrhea  in  children 
is  not  infrequently  the  result  of  accidental  contamination.  That  the 
bath  may  convey  the  infection  is  illustrated  by  a  report  from  Welt- 
Kakels,  who  referred  to  an  instance  occurring  in  Pose,  Germany, 
where  236  school  girls  acquired  vulvovaginitis  from  a  common  bath. 
Kelly  says  that  girls  are  infected  intentionally  through  a  somewhat 
prevailing  superstition  among  the  lower  classes  that  the  disease  can 
be  eradicated  if  it  is  transferred  to  a  healthy  person,  notably  a  virgin. 

Vidvovaginitis.— According  to  most  authorities  vulvovaginitis  exists 
in  about  1  per  cent,  of  female  children,  and  that  the  great  majority  of 
these  cases  are  gonorrheal.  It  is  the  exception  that  a  purulent  vaginal 
discharge  in  children  is  due  to  causes  other  than  gonorrheal.  The 
vulva  and  vagina  of  adults  are  not  easily  infected  because  of  the  presence 
of  multiple  layers  of.  fat  epithelium  arranged  in  palisade  form.  In 
children  these  structures  are  co\'ered  with  delicate  epithelium,  which 
affords  little  protection  against  invading  gonococci;  hence  the  frequency 
with  which  vulvovaginitis  is  found  in  children.  The  gonococci  pass 
between  the  epithelial  cells,  and  are  known  to  pass  beyond  the  epithelium 
into  the  subepithelial  tissue. 

Vulvovaginitis  in  children,  in  the  acute  stage  of  the  infection,  does 
not  differ  essentially  from  that  found  in  adult  life.  The  labia  are  swollen, 
red,  and  edematous.  The  hymen  and  inner  surfaces  of  the  labia  are 
sites  of  predilection,  and  the  inflammation  may  extend  to  the  perineum 
and  neighboring  skin  surfaces.  Condylomata  may  cover  the  vulvar 
and  peritoneal  surfaces  and  the  region  about  the  anus,  though  this  is 
exceptional.  The  infected  surfaces  are  usually  covered  with  a  greenish 
or  yellowish  discharge.  The  infection  may  end  here,  but,  as  a  rule, 
the  vagina  is  invaded. 

The  recognition  of  an  existing  vaginitis  is  not  difficult.  After  cleansing 
the  vulvar  surfaces,  pus  may  be  seen  to  exude  through  the  opening  of 
the  hymen,  or  a  very  small  speculum  may  be,  passed  into  the  vagina, 
though  this  latter  procedure  is  open  to  the  serious  objection  that  the 
disease  may  thereby  be  conve^'ed  from  the  vulva  to  the  vagina.  Certain 
so-called  congenital  anomalies  may  be  ascribed  to  gonorrhea  acquired 
in  titero,  i.  e.,  imperforate  hj-men,  adhesions  of  the  labia  and  prepuce, 
diseased  and  malformed  uteri,  and  Fallopian  tubes.  The  urethra  is 
frequently  the  seat  of  gonorrhea,  but  the  author  knows  of  only  one 
reported  case  in  which  the  infection  extended  to  the  bladder,  that  of 
Wertheim,  who  found  gonococci  in  the  epithelial  interspaces  of  the 


TREATMENT  537 

bladder,  in  the  wall  of  the  bladder,  and  within  the  bloodvessels  of 
the  bladder  wall. 

In  rare  cases  the  infection  may  extend  from  the  cervix  to  the  body 
of  the  uterus,  thence  to  the  tubes,  ovaries,  and  pelvic  peritoneum. 
Goodman  reported  eight  cases  of  gonorrheal  general  peritonitis,  with 
two  fatalities.  The  favorable  prognosis  of  gonorrheal  peritonitis  is 
worthy  of  note.  The  pathological  lesions  and  clinical  manifestations 
do  not  differ  from  those  found  in  adult  life.  Bandler  observes  that 
children  suffering  from  pelvic  or  general  gonorrheal  peritonitis  are 
commonly  assumed  to  have  appendicitis,  but  the  presence  of  a  gonor- 
rheal vulvovaginitis  should  lead  to  a  correct  diagnosis. 

Proctitis  occasionally  accompanies  a  vulvovaginitis  and  is  recognized 
by  itching  and  irritation  about  the  anus,  a  purulent  discharge  from  the 
rectum,  and  the  detection  of  gonococci  in  the  discharge.  Occasionally 
ulcers  are  developed  on  the  rectal  mucosa.  These  ulcers  may  give  rise 
to  a  bloody  discharge  from  the  rectum  and  to  painful  stools. 

Treatment. — Since  the  infection  is  most  frequently  conveyed  by 
napkins,  it  follows  that  all  napkins  worn  by  infected  children  should 
be  burned,  and  all  linen  should  be  soaked  in  an  antiseptic  solution, 
then  washed  and  sterilized.  In  cleansing  the  infected  parts  absorbent 
cotton  should  be  used  in  place  of  sponges.  Baths  should  not  be  given 
in  tubs  shared  by  other  patients  and  healthy  individuals.  Strict  isola- 
tion of  these  cases  should  be  maintained  in  hospitals,  hence  they  are 
not  to  be  cared  for  in  wards.  This  quarantine  should  embrace  the 
nurse  in  attendance  if  further  spread  of  the  disease  is  to  be  prevented. 
The  quarantine  should  not  be  raised  as  soon  as  the  local  signs  of  inflam- 
mation subside,  but  should  continue  so  long  as  the  presence  of  gonococci 
can  be  demonstrated  in  the  secretions. 

Bandler  recommends  painting  the  vulva  with  a  10  per  cent,  solution 
of  silver  nitrate.  Not  only  the  vulva  but  the  surrounding  skin  surfaces 
should  be  treated  in  like  manner.  Warm  sitz  baths  should  be  given 
once  or  twice  daily.  When  there  is  much  irritation  the  surfaces  should 
be  anointed  with  a  2  per  cent,  protargol  ointment.  Similar  remedies 
may  be  employed  in  the  treatment  of  gonorrheal  infection  of  the  rectum. 
Fissures  and  ulcers  should  be  cauterized  by  the  Paquelin  cautery.  It 
is  essential  to  enjoin  rest  in  bed  in  all  these  cases  throughout  the  acute 
stage. 

Butler  and  Long,  of  Chicago,^  in  making  a  report  of  their  clinical 
observations  with  gonorrheal  vaccine  in  the  treatment  of  vulvovaginitis 
in  children,  say: 

"The  contention  might  be  raised  that  gonorrhea  is  aggravated  in 
female  children  by  local  treatment  and  that  the  discontinuance  of 
such  treatment  might  be  expected  to  be  followed  by  betterment.  The 
possibility  of  this  should  be  conceded,  but  when  we  are  able  to  trace 
daily  variation  in  the  clinical  manifestations  with  the  ebb  and  flow 
of  the  wave  of  immunity,  when  we  see  within  twenty-four  hours  a 

1  Jour.  Amer.  Med.  Assoc,  March  7,  1908. 


538  GONORRHEA  IN  CHILDREN 

profuse  discharge  cease  and  find  negative  smears  coincident  with  a 
marked  rise  in  the  opsonic  index,  the  above  contention  loses  much  of 
its  weight,  and  in  the  cases  treated  must  be  excluded  from  consideration 
in  calculating  results. 

"If  from  our  work  any  conclusions  are  permissible,  we  believe  it  no 
exaggeration  to  state  that  vaccine  therapy  has  a  place  in  the  treatment 
of  gonorrhea  in  the  female,  that  it  appears  to  be  far  more  efficient, 
and  at  the  same  time  scientifically  more  tenable  than  local  antiseptic 
treatment," 

While  a  vulvovaginitis  usually  disappears  with  six  to  twelve  weeks' 
of  careful  treatment,  exacerbations  are  often  observed.  One  case  is 
recorded  where  the  disease  lasted  four  vears. 


CHAPTER  XXIV 


TUBERCULOSIS  OF  THE  GENITAL  ORGANS 


Etiology 

1.  Primary  Infection 

2.  Secondary  Infection 
Tuberculosis    of    the    Vulva   and 

Vagina 
Tuberculosis  of  the  Cervix 
Tuberculosis  of  the  Uterus 


Tuberculosis  op  the  Ovaries 
Tuberculosis    of    the     Fallopian 

Tubes 
Tuberculous  Peritonitis 
Prognosis 
Treatment 


Etiology. — ^While  the  knowledge  of  the  existence  of  genital  tuber- 
culosis in  women  dates  to  the  middle  of  the  eighteenth  century,  and  an 
accurate  and  exhaustive  contribution  on  the  pathogenesis,  diagnosis, 
and  surgical  treatment  was  presented  by  Hegar  as  early  as  1886,  yet 
it  may  be  stated  that  the  profession  in  general  fails  to  appreciate  the 
prevalence  of  the  disease. 

Essential  Causes. — ^The  essential  cause  of  tuberculosis  of  the  genital 
organs  is  the  tubercle  bacillus  of  Koch,  which  is  conveyed  to  the  genital 
organs  either  directly  by  hands,  instruments,  or  coitus,  or  indirectly 
by  way  of  the  bloodvessels  and  lymphatics  from  neighboring  and  distant 
portions  of  the  body. 

Predisposing  Causes. — As  predisposing  causes  to  tuberculosis  of  the 
genital  organs,  Hegar  mentions  general  and  local  malnutrition,  hypo- 
plasia, and  other  developmental  anomalies  of  the  genital  organs, 
puerperal  and  gonorrheal  infections,  syphilis  and  childbearing. 

Age. — Genital  tuberculosis  has  been  found  at  ah  periods  of  life. 
Feise  and  Schmorl  found  tubercles  in  the  genitals  of  a  fetus.  A  number 
of  cases  have  been  reported  in  ages  ranging  from  birth  to  eleven  years. 
More  than  50  per  cent,  of  all  cases  occur  before  thirty  years  of  age  and 
a  goodly  proportion  develop  in  childhood.  Still  estimates  that  9.5 
per  cent,  of  tuberculous  girls  under  twelve  years  of  age  have  genital 
tuberculosis.  It  is  exceptional  to  find  tuberculosis  developing  in  the 
genital  organs  after  forty  years  of  age. 

Frequency. — About  10  per  cent,  of  ah  forms  of  salpingitis  are  tuber- 
culous. In  795  autopsies  performed  by  Berkeley  on  tuberculous  cases 
62  showed  genital  tuberculosis.  The  proportion  of  women  suffering 
from  pulmonary  tuberculosis  who  have  genital  tuberculosis  is  variously 
estimated  at  6  to  12  per  cent.  In  955  autopsies  on  women  who  died  of 
pulmonary  tuberculosis,  the  lesion  was  found  in  the  genital  organs 
in  14.7  per  cent.  (Turner). 

Schlimpert  finds  about  2  per  cent,  of  genital  tuberculosis  in  his 
autopsies  on  women.  In  every  instance  there  were  active  or  latent 
foci  elsewhere  in  the  body.  He  demonstrated  that  the  infection  was 
conveyed  by  way  of  the  blood  stream  in  nearly  every  instance. 


540  TUBERCULOSIS  OF   THE  GEXITAL  ORGAXS 

In  all  Schlinipert  found  73  cases  of  genital  tuberculosis  Avith  the 
following  organs  involved:  Uterus,  41  times;  cervLx,  3  times;  vagina, 
7  times;  tubes,  51  times;  ovaries,  10  times.  In  about  one-half  the  cases 
the  peritoneum  was  involved. 

Genital  tuberculosis  occurs  about  five  times  as  frequently  in  the 
female  as  in  the  male.  Amann  estimates  that  3  per  cent,  of  tuberculous 
lesions  involve  the  genital  organs  of  the  male  as  compared  with  20  per 
cent,  in  the  female. 

Primary  infection  of  the  genital  organs  is  rare,  though  it  is  possible 
for  the  vulva,  vagina,  cervix,  uterus,  tubes,  and  ovaries  to  be  the 
primary  seat  of  infection.  Tubercle  bacilli  may  be  conveyed  direct  to 
these  organs  by  the  examining  finger,  by  instruments,  and  by  coitus 
with  a  tuberculous  male.  It  is  not  essential  that  the  male  genitals 
be  tuberculous  in  order  that  the  husband  may  transmit  the  disease 
to  the  genitals  of  the  wife.  Tubercle  bacilli  have  been  found  in  the 
semen  of  men  whose  genitals  were  free  of  tuberculosis  but  whose  lungs 
or  intestines  were  infected.  In  children  the  bacilli  have  been  conveyed 
to  the  genitals  from  infected  stools  and  from  soiled  linen. 

Without  a  postmortem  examination  of  all  organs,  it  is  not  possible 
to  speak  with  full  assurance  of  a  primary  lesion  in  the  genital  organs. 
A  clinical  examination,  however  searching,  may  fail  to  disclose  a  latent 
primary  focus  in  the  lungs,  intestines,  bones,  mesenteric  glands,  and 
elsewhere. 

Secondary  infection  of  the  genital  organs  is  not  uncommon  when 
tuberculous  foci  exist  in  adjacent  or  remote  regions  of  the  body.  From 
adjacent  structures  we  find  tuberculosis  extending  from  the  peritoneum 
to  the  tubes  and  ovaries  and  downward  to  the  uterus,  cervix,  vagina, 
and  vulva.  Again,  the  infection  is  conveyed  by  blood  and  lymph 
vessels  from  the  lungs,  mesenteric  glands,  intestines,  and  bladder  to 
the  genital  organs. 

We  will  here  discuss  ascending  and  descending  forms  of  genital 
tuberculosis. 

Ascending  tuberculosis  is  observed  in  a  small  percentage  of  cases. 
The  infection  in  rare  instances  begins  in  the  lower  genital  tract  and 
travels  upward  through  the  uterus  to  the  tubes,  ovaries,  and  peritoneum. 

Descending  tuberculosis  is  by  far  the  most  common.  The  lesion 
may  begin  in  the  peritoneum  and  extend  to  the  ovaries  and  tubes  and 
downward  to  the  uterus,  cervix,  vagina,  and  vulva,  though,  as  a  rule, 
the  disease  does  not  extend  lower  than  the  uterus. 

Tuberculosis  of  the  Vulva  and  Vagina.— Primary  tuberculosis  of  the 
vulva  and  \-agina  is  rare,  but  possible.  The  lesion  is  almost  invariably 
secondary  to  tuberculosis  in  the  tubes,  and  back  of  this  there  is  usually 
a  primary  focus  in  the  lungs  or  some  other  remote  organ.  The  lesion  is 
easily  confounded  with  lupus,  rodent  ulcer,  esthiomene,  cancer,  syphilis, 
and  phagedena.  (See  Chapter  XVII.)  Beyea  reported  69  cases  of 
tuberculosis  of  the  cervix,  19  of  this  number  being  limited  to  the 
portio  vaginalis  and  6  to  the  cervical  canal,  and  in  the  remaining  44 
both  portions  of  the  cervLx  were  involved. 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  541 

Tuberculosis  of  the  Cervix. — It  is  doubtful  if  tuberculosis  ever  exists 
as  an  isolated  lesion  in  the  cervix.  It  is  easily  confounded  with  car- 
cinoma and  syphilis.  Tuberculosis  is  seldom  found  to  coexist  in  the 
body  of  the  uterus  and  cervix.  The  tubes  and  cervix  may  be  involved 
and  the  uterus  remain  free  of  infection. 

Tuberculosis  of  the  Uterus. — Next  to  the  tubes  the  uterus  is  most 
often  involved.  In  172  cases  of  genital  tuberculosis  reported  by  Merlette 
the  uterus  was  invoh'ed  75  times.  Palano  reports  cases  ranging  in 
age  from  nine  and  a  half  months  to  sixty-four  years.  83  per  cent,  of 
all  cases  tabulated  by  Palano  dated  back  to  childbirth.  Tuberculous 
metritis  is  not  incompatible  with  pregnancy,  but  pregnancy  will 
commonly  cause  a  preexisting  tuberculous  lesion  to  become  active  and 
to  spread  to  adjacent  and  remote  tissues.  The  tuberculous  lesion  is 
commonly  confined  to  the  endometrium,  though  the  musculature  is 
known  to  be  invaded,  particularly  in  childhood. 

The  question  is  raised  as  to  whether  tuberculosis  is  ever  primary 
in  the  endometrium.  While  it  is  possible,  the  rule  is  that  the  endo- 
metrium is  invaded  from  the  tubes. 

Doederlein  recognized  three  types  of  tuberculous  endometritis,  the 
miliary,  interstitial,  and  ulcerative.     (See  page  423.) 

Tuberculosis  of  the  Ovaries. — In  nearly  every  instance  the  ovary  is 
infected  by  the  tubercle  bacillus  secondary  to  the  Fallopian  tubes  or 
peritoneum.  Wolff  finds  that  60  per  cent,  of  all  cases  of  tuberculous 
ovaries  are  associated  with  tuberculosis  of  the  tubes  or  peritoneum. 
Instances  are  recorded  in  which  the  ovary  was  the  only  pelvic  organ 
involved,  but  in  all  cases  there  was  a  remote  primary  focus.  The 
ovary  is  involved  in  one-third  of  all  cases  of  genital  tuberculosis,  and 
in  more  than  half  the  cases  the  lesion  is  bilateral.  It  must  be  borne 
in  mind  that  miliary  tubercles  may  be  scattered  throughout  the  ovary 
without  appearing  on  the  external  surface,  so  that  it  is  possible  to  over- 
look the  lesion,  even  with  the  abdomen  open.  Without  a  microscopic 
and  bacteriological  examination  the  lesion  may  not  be  recognized. 
(For  the  pathology  and  diagnosis  of  tuberculous  ovaritis  see  above.) 

Tuberculosis  of  the  Fallopian  Tubes. — While  the  Fallopian  tubes 
are  the  most  frequent  seat  of  genital  tuberculosis  the  lesion  is  seldom 
confined  to  the  tubes,  but  invades  adjacent  structures. 

In  a  small  percentage  of  cases  tuberculous  salpingitis  is  primary,  but 
in  nearly  every  instance  tuberculous  foci  are  found  elsewhere  in  the 
body,  and  the  infection  of  the  tubes  is  the  result  of  direct  extension 
from  surrounding  structures  or  the  bacilli  are  conveyed  from  the 
primary  focus  in  remote  organs  by  way  of  the  blood  or  lymph. 

Frequency  of  Tuberculous  Salpingitis. — The  tubes  are  involved  in 
about  90  per  cent,  of  all  cases  of  genital  tuberculosis,  and  the  infection 
is  confined  to  the  tubes  in  about  one-fourth  of  this  number.  In  4470 
autopsies  performed  on  women  by  Schraum,  Frerichs,  and  von  Rosthorn, 
tuberculous  salpingitis  was  found  53  times.  In  814  cases  of  salpingitis 
(Williams,  Martin,  von  Rosthorn),  tuberculosis  was  found  29  times. 

In  17,470  autopsies  on   women   performed  in  the  German  clinics 


542  TUBERCULOSIS  OF  THE  GENITAL  ORGANS 

tuberculosis  of  the  tubes  was  found  in  142  cases,  or  1  in  123.  About 
1  per  cent,  of  all  female  cadavers  have  tuberculosis  in  the  tubes.  In 
a  total  of  884  observations  made  by  Williams,  Martin,  Menge,  and 
von  Rosthorn  there  was  an  average  of  6.2  per  cent,  of  tuberculosis 
found  in  all  forms  of  salpingitis. 

Age  of  Appearance. — No  age  is  exempt.  It  has  been  found  in  utero 
at  seven  months  and  at  the  age  of  seventy-nine  years.  The  most 
susceptible  period  is  between  twenty  and  thirty  years  of  age,  though 
the  period  of  ten  to  twenty  and  thirty  to  forty  are  but  little  less  sus- 
ceptible.    It  is  rare  that  the  disease  occurs  after  forty  years  of  age. 

Avenues  of  Invasion. — The  tube  is  invaded  by: 

1.  Continuity  of  tissues  (peritoneum,  uterus,  vagina,  bowel,  and 
bladder). 

2.  Bloodvessels  and  lymph  vessels.  More  often  the  lungs  are  the 
primary  seat  of  infection. 

Why  are  the  Fallopian  tubes  more  liable  to  tuberculosis  than  the  other 
genital  organs? 

Hegar  and  Sippel  offer  the  explanation  that  the  irregularities  in  the 
mucosa  of  the  tubes  favor  the  lodgement  of  tubercle  bacilli.  Amann 
further  adds  the  theory  that  the  convolutions  of  the  tubes  and  the 
impoverished  blood  supply  favor  the  invasion  of  tubercle  bacilli. 
Gonorrheal  infection  of  the  tubes  will  doubtless  lower  the  resistance 
of  the  tissues  and  render  them  more  susceptible  to  tuberculosis. 

Pathology  and  Diagnosis. — (See  page  541.) 

Treatment  of  Genital  Tuberculosis. — The  question  of  operative 
interference  naturally  arises  in  a  discussion  of  the  treatment  of  genital 
tuberculosis.  In  deciding  this  question,  inquiry  must  be  made  (1) 
as  to  whether  genital  tuberculosis  leads  directly  to  a  fatal  issue,  and 
(2)  as  to  whether  genital  tuberculosis  leads  to  invalidism, 

7^  genital  tuberculosis  a  direct  cause  of  death  f 

A  survey  of  the  literature  convinces  the  author  that  death  is  rarely 
attributed  directly  to  genital  tuberculosis.  Simmonds,  of  Hamburg, 
has  never  observed  a  death  which  he  could  ascribe  to  genital  tuber- 
culosis. Schmorl  and  Schlimpert  report  144  autopsies  in  which  genital 
tuberculosis  was  found,  and  in  none  of  these  cases  was  the  death 
directly  caused  by  the  pelvic  lesion,  though  in  two  instances  the  pelvic 
lesion  was  a  contributing  factor. 

It  follows  that  there  is  seldom  if  ever  a  vital  indication  for  operative 
interference  in  genital  tuberculosis. 

The  second  question  is  not  so  easily  disposed  of. 

Does  the  genital  tuberculosis  produce  symptoms  which  justify  operative 
interference? 

We  have  the  authority  of  Doederlein  and  Kroenig  that  ^genital 
tuberculosis  rarely  gives  rise  to  a  miliary  tuberculosis  and  that  ulceration 
seldom  develops  between  the  genital  tract  and  the  bladder  or  rectum. 
There  is  much  difference  of  opinion  as  to  the  frequency  of  the  develop- 
ment of  general  tuberculous  peritonitis  from  a  primary  focus  in  the 
genital  organs.    There  is  an  evident  lack  of  harmony  in  the  views  of 


TREATMENT  OF  GENITAL   TUBERCULOSIS  543 

anatomists  and  clinicians  on  this  important  point.  Schickele,  of 
Freiburg,  finds  but  little  tendency  in  this  direction.  The  prevailing 
impression  among  clinicians  appears  to  be  that  there  is  liability  of 
spreading  the  infection  from  the  uterine  appendages  to  the  peri- 
toneum. 

In  considering  this  point  it  must  be  borne  in  mind  that  genital  tuber- 
culosis is  rarely  primary;  that  in  the  great  majority  of  cases  the  primary 
lesion  is  in  the  lungs  or  intestines.  It  is  therefore  manifestly  difficult 
to  judge  the  symptom-complex  and  determine  with  certainty  what 
should  be  credited  to  the  lesion  in  the  lung  or  bowel  and  what  to  the 
genital  organs. 

Symptoms  directly  due  to  genital  tuberculosis  are  seldom  severe 
and  can  usually  be  relieved  by  palliative  measures.  The  paroxysmal 
pains  give  way  to  rest  and  the  application  of  heat.  The  hemorrhages, 
which  occur  in  but  a  small  percentage  of  cases,  are  in  reality  the  only 
urgent  indication  for  operative  interference.  In  tuberculous  endome- 
tritis, Hegar  advises  curettage  of  the  uterus,  but  Schauta  and  Pozzi 
believe  curettage  to  be  merely  a  palliative  measure  in  temporarily 
checking  the  bleeding.  They  argue  that  curettage  is  not  a  harmless 
procedure  because  of  the  danger  of  spreading  the  infection,  of  adding 
a  secondary  type  of  infection,  and  of  awakening  a  latent  infection  in 
the  lungs  or  elsewhere. 

The  conclusion  is  forced  upon  us  that  a  radical  operation  is  rarely 
justified  for  relief  from  symptoms  caused  by  genital  tuberculosis. 
This  is  so  because: 

1.  The  symptoms  directly  referable  to  genital  tuberculosis  are  rarely 
severe  and  will  usually  yield  to  palliative  measures. 

2.  Operative  measures  may  cause  an  awakening  of  a  latent  primary 
focus  and  result  in  a  local  or  general  dissemination  of  the  infection. 

3.  There  is  a  relatively  high  primary  mortality  in  these  operations. 
Doederlein's  estimate  is  10  per  cent. 

4.  Since  genital  tuberculosis  occurs  with  greatest  frequency  in  girl- 
hood and  early  womanhood,  and  the  tuberculous  lesion  is  seldom  con- 
fined to  one  portion  of  the  genital  tract,  operative  interference  may 
result  in  an  unwanton  sacrifice  of  organs. 

5.  There  is  a  marked  tendency  toward  self-limitation  and  sponta- 
neous healing  in  genital  tuberculosis. 

To  what  extent  should  the  operation  be  carried  f 

Inasmuch  as  the  tubes  are  almost  always  the  primary  seat  of 
infection,  so  far  as  concerns  the  genital  organs,  the  rule  is  generally 
followed  to  remove  only  the  tubes.  Both  tubes  are  involved  in  about 
90  per  cent,  of  cases. 

The  ovaries  are  only  removed  when  there  are  evident  tuberculous 
lesions  in  the  ovaries.  It  is  questionable  if  both  ovaries  should  be 
removed  in  young  women  unless  the  disease  is  far  advanced. 

The  uterus  should  be  removed  when  infected  if  the  patient  is  advanced 
in  years  and  if  there  is  uncontrollable  bleeding. 

In  tuberculosis  of  the  cervix,  unaccompanied  by  an  involvement 


544  TUBERCULOSIS  OF  THE  GENITAL  ORGANS 

of  the  upper  genital  tract,  a  high  amputation  of  the  cervix  should  be 
made. 

In  tuberculosis  of  the  vulva  and  vagina,  ulcers  may  be  cauterized 
or  excised  and  papillary  growths  may  be  removed,  though  here  the 
.r-rays  are  of  special  value. 

Tuberculous  Peritonitis. — According  to  Nothnagel  90  per  cent,  of 
tuberculous  peritonitis  is  found  in  the  female.  In  former  years  tuber- 
culous peritonitis  was  believed  to  be  almost  uniformly  fatal.  In 
recent  literature  we  find  contradictory  views  expressed.  Some  would 
have  it  that  the  disease  is  largely  amenable  to  surgery;  others  that 
the  indications  for  operative  interference  are  necessarily  restricted  to 
a  small  percentage  of  cases. 

Indications  for  Treatment. — The  purpose  of  treatment,  according  to 
Murphy,  is  fourfold: 

1.  To  remove  the  source  of  supply  to  the  peritoneum. 

2.  To  remo^'e  from  the  peritoneum  the  products  of  the  infective 
process. 

3.  To  increase  tissue  resistance  for  the  purpose  of  encapsulating 
the  remaining  tuberculous  foci. 

4.  To  avoid  mixed  infection. 

JVhat  is  ihe  cause  of  death  in  tuberculous  peritonitis f 
Death  may  result  from: 

1.  Mechanical  ileus  due  to  adhesions. 

2.  Toxic  absorption. 

3.  Rupture  of  tuberculous  ulcers  of  the  bowel  into  the  free  peritoneal 
cavity. 

Postmortem  observations  reveal  that  the  cause  of  death  in  90  per 
cent,  of  cases  is  due  to  the  primary  focus  in  the  lungs,  meninges,  or  to 
general  miliary  distribution,  ^yhen  possible  the  primary  focus  (tubes, 
appendix)  should  be  removed;  this  will  increase  the  percentage  of 
cures  and  decrease  the  percentage  of  recurrences.  The  fimbriated  end 
of  a  tuberculous  tube  usually  remains  open,  and  so  long  as  this  condition 
prevails  the  peritoneum  is  continually  supplied  with  fresh  tuberculous 
material.  Furthermore,  the  tuberculous  lesion  in  the  mucosa  of  the 
tubes  is  slow  to  heal.  For  these  reasons  the  infected  tubes  should  be 
removed  when  found  in  the  presence  of  a  tuberculous  involvement  of 
the  peritoneum. 

Abdominal  Section. — The  percentage  of  cures  following  abdominal 
section  for  tuberculous  peritonitis  is  recorded  by  Koenig  as  65  per  cent., 
Margarucci  as  85  per  cent.,  Roersch  as  70  per  cent.,  and  Wunderlich 
as  20  per  cent.  The  difference  in  results  is  largely  accounted  for  by 
the  difference  in  indications  for  operative  interference. 

Some  would  operate  only  in  the  exudative  type,  while  others  Avould 
include  the  adhesive  and  ulcerative  types.  Again,  there  are  surgeons 
who  will  not  open  the  abdomen  in  the  presence  of  an  active  focus  in 
the  lung  or  elsewhere,  while  others  will  disregard  such  complications. 
Then,  too,  in  the  making  of  statistics  some  operators  include  all  deaths: 
those  due  directly  to  tuberculous  peritonitis  and  those  due  to  tuber- 


TUBERCULOUS  PERITONITIS  545 

culosis  of  other  regions.  The  only  reliable  statistics  are  those  based 
upon  a  pathological  classification. 

To  what  extent  does  tuberculous  peritonitis  affect  the  health  of  the  indi- 
vidual? 

Doederlein  believes  that  a  large  percentage  are  not  seriously  affected. 
He  says  that  fully  50  per  cent,  of  the  women  who  enter  his  clinic  with 
tuberculous  peritonitis,  and  are  subsequently  operated  upon,  complain 
of  sterility  and  have  little  or  no  distress  in  the  abdomen.  Some  com- 
plain only  of  backache  and  others  of  a  large  abdomen.  Few  suffer 
from  severe  pain  or  hemorrhage. 

Of  those  who  are  seriously  debilitated,  and  they  constitute  the  other 
50  per  cent,  of  cases,  the  debility  is  largely  attributable  to  the  primary 
focus  in  the  lungs  or  bowel  rather  than  to  the  peritoneum  or  pelvic 
organs. 

Primary  Mortality  of  Abdominal  Section. — The  primary  mortality  of 
abdominal  section  for  tuberculous  peritonitis  is  relatively  high.  Ivroenig 
gives  3  per  cent.,  Lindner  7.5  per  cent.,  and  Doederlein  12  per  cent. 

The  following  rules  will  govern  abdominal  section  for  tuberculous 
peritonitis : 

1.  Operate  in  only  the  exudative  type.  The  adhesive  and  ulcerative 
types  are  not  favorable  subjects  for  operation. 

2.  Do  not  operate  in  the  presence  of  a  fever  or  when  there  is  an 
active  focus  of  tuberculosis  in  the  body. 

Borchgrevink  recommends  medical  treatment  in  tuberculous  peri- 
tonitis. He  says  that  when  peritoneal  tuberculosis  exists  without  fever 
the  disease  will  usually  run  a  favorable  course  and  does  not  require 
a  laparotomy. 

Medical  Treatment. — Medical  treatment  of  tuberculous  peritonitis  is 
the  same  as  that  employed  in  the  management  of  tuberculosis  of  the 
lungs.  Good  food  and  fresh  air  are  essential.  Such  tonics  as  cod-liver 
oil  do  not  in  the  least  supersede  fresh  air  and  an  abundance  of  nourish- 
ing food.  No  medicine  should  be  given  that  will  disturb  the  stomach 
and  interfere  with  the  ingestion  of  food. 

Tuberculin  has  been  extolled,  but  it  is  not  clear  that  its  value  is 
great  as  a  curative  agent.  Cures  by  the  administration  of  tuberculin 
have  been  reported  by  Gray,  Rumph,  McCall,  Leser,  Kummel,  and 
Riegel.  Von  Ruck  gives  encouraging  reports,  having  a  record  of  3 
cures  in  4  cases;  82.3  per  cent,  of  Borchgrevink's  cases  were  cured 
by  medicinal  means. 

Johnston  in  a  review  of  the  statistics  says:  "By  comparing  the 
statistical  results  of  cases  that  have  been  observed  for  a  sufficient  time 
after  treatment,  one  is  impressed  with  the  fact  that  the  figures  are 
about  the  same  in  those  treated  surgically  as  in  those  treated  by  medi- 
cinal means,  and  one  may  conclude  that  the  prognosis  for  recovery 
is  good  in  one-fourth  to  one-third  of  all  cases  of  tuberculosis  of  the 
peritoneum." 


35 


CHAPTER   XXV 

NUTRITIONAL  DISTURBANCES  OF  THE   GENITAL 

ORGANS 

Retrogressive  Tissue  Changes  Progress^:  Tissue  Ch.\xges 

Atrophy  of  the  Vulva  (Ivraurosis  Elephantiasis  Vulvae 

Vulvse)  Condyloma  Acuminata 

Atrophy  of  the  "N'agina  Hypertrophy  of  the  Vulva 

Atrophy  of  the  Uterus  H^iDertrophy  of  the  CUtoris 

Physiological  Atrophy  H}-pertrophy  of  the  Labia 

Superinvolution  of  the  Uterus  H}-pertrophy  of  the  Cer^^x 

Atrophy  of  the  Ovary  Supravaginal  H^-pertrophy 

Infravaginal  H^-pertrophj' 
Subinvolution  of  the  Uterus 
HA'pertrophy  of  the  Ovary 

There  are  found  throughout  the  genital  tract  certain  nutritional 
disturbances  which  cannot  be  grouped  with  inflammations  or  tumor 
formations,  and  so  for  convenience  are  incorporated  in  a  separate 
chapter.  These  nutritional  changes  may  be  classified  as  retrogressive 
and  progressive  tissue  changes. 


RETROGRESSIVE  TISSUE  CHANGES 

Atrophy  of  the  Vulva  (Kraurosis  Vulvas). — After  the  menopause  there 
occurs  a  physiological  atrophy  of  the  vulva  in  which  the  labia  majora 
lose  their  plumpness,  the  labia  minora  diminish  in  size  and  may  wholly 
disappear,  the  clitoris  is  shortened,  the  mucous  membrane  becomes 
dry  and  pale,  and  the  vulvar  orifice  is  narrowed. 

Kraurosis  vulvae  is  a  term  applied  to  a  specific  form  of  atrophy  of 
the  vulva,  the  cause  of  which  is  not  known.  The  extent  of  the  atrophy 
may  be  greater  than  that  found  in  old  age.  The  labia  majora  are 
flat  and  flaccid;  while  the  mucosa  may  be  so  friable  as  to  be  injured 
by  the  examining  finger.  The  labia  minora  and  clitoris  may  wholly 
disappear.  In  addition  to  the  dryness  of  the  surface  there  is  extreme 
sensitiveness.  Dyspareunia  is  a  common  complaint,  and  when  asso- 
ciated with  itching  and  a  sense  of  dryness  in  the  vulva,  the  possibility 
of  kraurosis  is  to  be  borne  in  mind  (Fig.  355). 

Kraurosis  occurs  chiefly  in  women  of  advanced  age;  in  women  who 
have  borne  children  and  have  become  sterile;  in  the  married  and  in 
the  widow.  The  lesion  sometimes  follows  removal  of  the  ovaries. 
That  it  is  due  to  syphilis  and  gonorrhea  is  quite  improbable.  The 
lesion  is  probably  of  inflammatory  origin.      The  glandular  structures 


RETROGRESSIVE  TISSUE  CHANGES  547 

of  the  affected  area  disappear;  the  papillae  are  poorly  developed    and 
the  conum  is  atrophied. 

Fig.  355 


Kraurosis  vulvae.     Clitoris  and  labia  minora  completely  atrophied;    the  labia  majora  flattened  and 

wrinkled.     (Gerhard.) 

Fig.  356 


Kraurosis  vulvae.    Marked  hornification  of   the  cerium,  with  round-cell  infiltration;  papilla 
are  absent.     (Gerhard.) 

PaUiative  Treatment.— The  pain,  pruritus,  and  burning  of  kraurosis 
vulvae  demand  relief  so  far  as  may  be  given.  Local  applications  afford 
only  temporary  relief,  if  any.  Relief  may  be  afforded  for  some  time  by 
the  application  of  a  10  per  cent,  solution  of  nitrate  of  silver  or  of  pure 


548      NUTRITIONAL  DISTURBANCES  OF  THE  GENITAL  ORGANS 

carbolic  acid.     Hot  fomentations  are  soothing.     The  vulva  should 
be  kept  smeared  with  a  3  per  cent,  carbolo-salve;   this  protects  the 


Fig.  357 


Fig.  358 


Kraurosis  vulvae. 


Fig.  359 


Margins  of  denuded  area  approximated. 


Removal  of    area   involved   in   kraurosis   vulvae. 
Dotted  lines  represent  area  of  denudation. 

surface  from  the  irritating  influences  of 
the  urine.  A  gauze  pad  soaked  in  a 
saturated  solution  of  the  acetate  of 
lead  will  afford  some  relief. 

Operative  Treatment. — When  palli- 
ative measures  fail,  relief  can  only  be 
obtained  through  operative  interfer- 
ence. A  forcible  stretching  of  the 
vulvar  outlet  will  sometimes  give 
relief  for  a  considerable  period,  but 
permanent  relief  can  only  come  from 
excision  of  the  affected  skin  surface. 

Technic  of  Operation. — An  incision 
is  made  with  the  knife  2  cm.  outside 
the  involved  area.  The  skin  is  dis- 
sected off  and  the  margins  approxi- 
mated with  interrupted  silkworm-gut 
sutures. 

When  the  greater  portion  of  the 
vulva  is  involved  the  typical  operation 
is  carried  out  as  illustrated  in  Figs.  357, 
358,  and  359. 


RETROGRESSIVE  TISSUE  CHANGES  549 

Atrophy  of  the  Vagina. — (See  Atresia  of  the  Vagina,  Senile 
Vaginitis,    page    409.) 

Atrophy  of  the  Uterus. — Physiological  Atrophy. — Physiological  atrophy 
of  the  uterus  follows  the  menopause.  Similar  changes  in  the  uterus 
follow  the  removal  of  the  ovaries. 

Superinvolution  of  the  Uterus. — (Secondary  Atrophy,  Puerperal 
Atrophy,  Lactation  Atrophy.) — In  this  condition  the  puerperal  uterus 
has  involuted  beyond  the  normal  limits  and  may  be  reduced  to  one- 
half  or  one-third  the  normal  size.  As  a  rule,  the  tubes  and  ovaries 
share  in  the  atrophic  changes. 

Etiology. — 

1.  Postpartum  and  postabortive  hemorrhages. 

2.  Puerperal  sepsis. 

3.  Prolonged  lactation. 

4.  Wasting  diseases  complicating  the  puerperium. 

Secondary  atrophy  of  the  uterus  and  ovaries  may  be  due  to  con- 
stitutional disturbances,  leading  to  malnutrition  or  to  indefinite 
embryological  disturbances.  Not  infrequently  these  conditions  can 
be  traced  to  the  diseases  of  childhood,  notably  scarlet  fever,  measles, 
mumps,  and  diphtheria.  When  the  development  of  the  ovaries  is 
checked,  there  must  of  necessity  follow  atrophic  changes  in  the  uterus 
and  tubes.  This  is  so  because  the  internal  secretion  of  the  ovary  is 
essential  to  the  development  of  these  organs. 

Chlorosis  is  believed  by  many  to  be  associated  with  a  faulty  secretion 
of  the  ovaries.  This  theory  finds  support  in  the  fact  that  chlorosis 
occurs  exclusively  in  girls  at  an  age  corresponding  to  their  sexual 
development,  between  the  ages  of  twelve  and  twenty.  Von  Noorden 
advances  the  theory  that  the  internal  secretion  of  the  ovary  stimulates 
the  blood-forming  centres,  and  when  this  secretion  is  lacking  there  is 
an  underdevelopment  of  blood.  In  further  support  of  von  Xoorden's 
theory  is  the  common  finding  of  poorly  developed  genital  organs  in 
chlorotic  girls.  About  75  per  cent,  of  chlorotic  girls  suffer  from  a 
partial  or  complete  loss  of  their  menstrual  functions.  They  usually 
menstruate  early  rather  than  late  in  life. 

Obesity  may  be  associated  with  underdevelopment  of  the  ovaries, 
tubes,  and  uterus,  and  hence  with  a  faulty  functionating  capacity  of 
these  organs.  The  tendency  to  lay  on  fat  is  probably  secondary  to 
the  atrophic  changes  in  the  ovaries,  and  suggests  the  tendency  of 
women  to  increase  in  w^eight  after  the  menopause.  Associated  with 
the  loss  of  ovarian  secretion  is  the  loss  of  the  thyroid  secretion,  as  has 
been  frequently  demonstrated. 

Symptoms. — 

1.  i^menorrhea. 

2.  Sterility. 

3.  Nervous  disorders. 

The  patient  either  fails  to  resume  the  menstrual  functions  or  men- 
struates but  little,  depending  upon  the  degree  of  atrophy.  Unless  the 
atrophy  is  checked  before  the  atrophic  changes  become  pronounced 


550     XUTRITIOXAL  DISTVRBAXCES  OF  THE  GEXITAL  ORGAXS 

the  capacity  for  childbearing  will  be  lost.  Such  individuals  are  usually 
classed  as  neurotics.  They  complain  of  general  debility,  headaches, 
lumbosacral  pains,  and  gastro-intestinal  disturbances. 

Diagnosis, — The  diagnosis  is  suggested  by  the  history,  ^^^len  the 
patient  has  been  perfectly  regular  in  her  menstrual  history,  has  given 
birth  to  a  child,  and  one  or  more  of  the  above  causal  factors  have  been 
interjected,  and  following  childbirth  the  physiological  period  of  lactation 
is  prolonged  beyond  the  usual  period,  the  presumption  is  that  the  uterus 
has  involuted  beyond  the  normal  limits.  The  diagnosis  is  confirmed 
by  a  bimanual  examination  and  by  the  passage  of  a  sound  into  the 
uterus.  If  the  uterine  cavity  is  less  than  two  and  a  half  inches  in 
depth  the  diagnosis  of  superinvolution  is  established.  If  the  cervix  is 
inspected  through  a  speculum  and  is  found  smaller  than  normal,  it  is 
assumed  that  the  body  of  the  uterus  is  correspondingly  small,  though 
this  is  not  always  the  case. 

Prognosis. — A  moderate  degree  of  atrophy  may  be  corrected  by 
increasing  the  nutrition  of  the  patient,  but  a  well-advanced  atrophy 
cannot  be  remedied. 

Treatment. —  General  Treatment. — Whatever  will  improve  the  general 
nutrhion  will  tend  to  develop  the  uterus.  A  nutritious  diet,  exercise 
in  the  open  air,  indoor  gymnastics,  cold  baths,  are  all  of  value.  Tonics 
of  iron  and  arsenic,  such  as  Bland's  pill  and  Fowler's  solution,  may  be 
indicated. 

Local  Treatment. — The  pelvic  circulation  may  be  stimulated  by 
massage  and  short,  hot  douches.  The  wearing  of  a  stem  pessary  is 
also  recommended. 

Atrophy  of  the  Ovary. — The  physiological  atrophy  of  the  ovary  in 
the  climacteric  may  occur  some  time  before  the  menstrual  periods 
altogether  cease,  or  may  be  delayed  many  years.  Atrophy  of  the 
ovary  usually  precedes  the  menopause  by  a  year  or  more,  but  is  seldom 
complete  for  several  years  after  the  menopause. 

A  pathological  atrophy  of  the  ovary  results  from  interference  with 
the  nutrition  of  the  organ  and  from  direct  and  continuous  pressure 
upon  the  ovary  by  tumor  formations  and  inflammatory  exudates. 
Inflammatory  adhesions  may  contract  about  the  ovary  and  tube,  limit- 
ing the  blood  supply  and  bringing  on  atrophy.  Swellings  of  the  tubes, 
uterus,  and  ovaries  may  cause  pressure  atrophy.  Atrophy  of  the  ovary 
may  follow  the  infectious  and  contagious  diseases,  s\'philis,  diabetes, 
the  primary  and  secondary  anemias,  myxedema,  morbus  Basedowii, 
tabes  dorsalis,  acromegaly,  and  poisoning  by  arsenic  and  phosphorus. 
Varicosities  of  the  veins  of  the  mesovarium  have  been  reported  by 
Palmer  Dudley  as  being  responsible  for  atrophy  of  the  ovary.  ]\Iartin, 
in  his  report  of  40  cases,  takes  the  position  that  the  majority  of  women 
with  atrophied  ovaries  suffer  from  pulmonary  tuberculosis. 

The  menstrual  functions  become  less  active  as  the  atrophy  of  the 
ovaries  progresses.  The  indi^'idual  often  increases  in  weight.  Nervous 
disturbances  are  frequently  complained  of,  such  as  pain  and  throb- 
bing in  the  head,  flashes  of  heat  and  cold,  insomnia,  irritability  of  temper, 


PROGRESSIVE  TISSUE  CHANGES 


551 


and  despondency.  A  positive  diagnosis  is  reserved  until  direct  inspection 
of  the  ovaries  can  be  made.  Atrophy,  together  with  cystic  degeneration, 
frequently  explains  the  early  occurrence  of  the  menopause. 

Treatment. — The  author  knows  of  no  treatment  that  will  correct 
the  atrophic  changes  in  the  ovaries,  but  there  is  in  the  corpus  luteum 
extract  a  remedy  that  will,  in  a  measure, 
afford  a  substitute  for  the  diminished  fi*^-  ^eo 

ovarian  secretions,  and  in  this  way  will 
help  to  control  the  nervous  phenomena 
incident  to  the  loss  of  ovarian  function. 


PROGRESSIVE  TISSUE  CHANGES 

Elephantiasis  Vulvae. — In  the  early 
stage  of  development  the  growth  is  not 
unlike  simple  hypertrophy,  but  as  it 
progresses  it  tends  to  become  more  and 
more  pedunculated  and  may  extend  to 
the  knees,  weighing  several  pounds. 
^^^len  the  surface  is  smooth  it  is  known 
as  elephantiasis  glabra;  when  nodular, 
elephantiasis  tuberculosa,  and  when 
covered  with  warty  excrescences,  ele- 
phantiasis condylomata.  The  surface 
may  be  more  or  less  ulcerated  (Fig.  362). 

The  point  of  origin  may  be  the  labia 
majora,  labia  minora,  mons  veneris,  or 
clitoris.  It  is  unusual  for  the  growth  to 
arise  simultaneously  from  two  or  more 
of  these  surfaces. 

The  greater  portion  of  the  growth  is 
of  connective  tissue,  with  edematous 
infiltration  of  the  connective-tissue 
spaces.  There  is  a  scant  blood-supply 
to  these  growths. 

The  essential  cause  is  the  filaria  san- 
guinis hominis.  Elephantiasis  some- 
times arises  from  the  base  of  old  ulcers 
and  suppurating  buboes.  Stenosis  or 
occlusion  of  the  lymph  channels  is 
undoubtedly  an  underlying  factor,  but 
the  cause  of  obstruction  to  the  lymph 
channel  is  unknown.  The  patient  consults  the  physician  because  of 
the  weight  of  the  growth  and  its  interference  with  walking  and  coition. 

Diagnosis. — The  diagnosis  will  involve  little  difficulty.  It  is  distin- 
guished from  carcinoma  by  the  absence  of  friability,  the  slow  growth, 
and,  finally,  by  a  microscopic  section  showing  an  absence  of  epithelial 


Elephantiasis  of  the  \ailva. 
Pettit.) 


(Bonnet  and 


552     NUTRITIONAL  DISTURBANCES  OF  THE  GENITAL  ORGANS 

invasion  of  the  connective  tissue  and  the  presence  of  connective-tissue 
hyperplasia.    There  are  no  constitutional  effects. 

Treatment. — The  treatment  is  both  medical  and  surgical. 

Medical  Treatment. — It  is  only  in  the  acute  stage  that  medical  treat- 
ment will  avail  anything.  At  this  time  the  patient  should  be  kept  in 
bed  and  hot  fomentations  applied  to  the  affected  parts.  The  application 
of  gauze,  saturated  in  a  lead-water  and  laudanum  solution,  will  help  to 
allay  the  acute  inflammation.  When  the  inflammation  has  subsided 
to  a  degree,  mercurial  ointment  should  be  applied  daily.  The  iodide 
of  potassium  or  sodium  may  be  given  internally.  Throughout  the 
acute  and  subacute  stages,  a  soft  but  firm  compress  of  gauze  should 
be  applied  to  the  vulva  and  supported  by  a  T-binder.  The  a;-rays  have 
been  used  with  good  results  in  the  chronic  stage. 

Surgical  Treatment. — When  the  disease  has  advanced  to  the  chronic 
stage  and  has  attained  considerable  proportions  surgery  may  be  invoked. 
The  hypertrophied  parts  should  be  excised. 

Condyloma  Acuminata. — Of  the  hypertrophic  lesions  due  to  inflam- 
mation, the  most  common  are  the  condylomata  acuminata,  which  are 
almost  invariably  of  gonorrheal  origin.  Dr.  Richard  R.  Smith  reported 
an  advanced  case  in  a  child,  aged  nineteen  months  (Fig.  361).  R.  L. 
Dickinson  in  discussing  "Hypertrophies  of  the  Labia  Minora  and 
Their  Significance,"  reported  373  cases,  and  gave  as  his  conviction 
that  all  were  due  to  the  habit  of  masturbating.^ 

The  development  of  condylomata  is  particularly  rapid  during  preg- 
nancy, and  is  said  to  be  caused  by  the  irritating  vaginal  discharge.  In 
the  early  stage  of  the  development  these  warty  outgrowths  are  pale 
red  or  gray.  Later  the  papillary  projections  become  confluent  and 
may  assume  the  proportions  of  a  man's  fist.  Occasionally  the  growth 
is  pedunculated.  They  are  found  distributed  over  part  or  all  of  the 
vulva,  vagina,  and  the  neighboring  skin  surface  of  the  mons  veneris, 
groin,  buttocks,  and  perineum.  The  lesion  is  essentially  an  overgrowth 
of  the  papillse.  The  greater  part  of  the  growth  is  due  to  an  increase 
in  the  epithelial  covering  of  the  papillae.  In  general  appearance  such 
a  gro\\i:h  is  not  unlike  a  cauliflower  carcinoma.  The  distinction  is 
made  by  the  frequent  occurrence  of  the  growth  during  pregnancy 
by  the  history  of  gonorrhea,  and  by  the  presence  of  gonococci  in  the 
secretions,  together  with  other  evidences  of  gonorrhea;  by  the  age 
of  the  individual,  and,  finally  and  conclusively,  by  the  microscopic 
examination  of  an  excised  piece  in  which  there  is  an  absence  of  epi- 
thelial invasion  of  the  underlying  connective  tissue. 

Treatment. — All  venereal  warts  should  be  excised  with  scissors  and 
the  base  cauterized  with  the  thermocautery.  This  usually  requires 
an  anesthetic.  When  observed  in  pregnancy  these  growths,  should 
be  removed  prior  to  labor  as  a  preventive  measure  to  sepsis  in  the 
mother  and  ophthalmia  in  the  newborn. 

In  cases  of  moderate  severity,  before  resorting  to  operative  procedures, 

1  American  Gj^necology,  September,  1902. 


PROGRESSIVE  TISSUE  CHANGES 


553 


the  application  of  equal  parts  of  calomel  and  salicylic  acid  may  be  tried 
as  a  dusting  powder,  or  an  ointment  of  zinc  oxide  and  the  subnitrate 
of  bismuth  may  be  applied.  During  this  treatment  frequent  douches 
of  bichloride  of  mercury  (1  to  4000)  are  given  and  the  patient  kept  at 
rest. 


Fig.  361 


Condyloma  acuminata  in  a  child  aged  nineteen  months.     (Case  of  Dr.  R.  R.  Smith.) 


Hypertrophy  of  the  Vulva. — Precocious  Development  of  the  Vulva.— 
A  precocious  development  of  the  vulva  is  occasionally  seen  in  infancy. 
This  condition  is  usually  accompanied  by  an  overdevelopment  of  the 
breasts  and  the  early  appearance  of  the  catamenia. 

Hypertrophy  of  the  Clitoris. — A  moderate  enlargement  of  the  clitoris 
is  not  rare,  but  in  exceptional  cases  the  clitoris  may  assume  the  pro- 
portions of  the  penis.  In  this  event  amputation  of  the  hypertrophied 
clitoris  is  required. 

Hypertrophy  of  the  Labia. — The  labia  are  sometimes  enormously 
enlarged.  Occasionally  they  are  so  large  as  to  be  a  source  of  embar- 
rassment to  intercourse.  Among  the  Hottentots  the  labia  minora  are 
known  to  hang  between  the  thighs  for  a  distance  of  several  inches — 
the  so-called  "Hottentot  apron." 

Hypertrophy  of  the  Cervix. — The  cervix  may  be  hypertrophied  above 
or  below  the  vaginal  attachment. 


554     NUTRITIONAL  DISTURBANCES  OF  THE  GENITAL   ORGANS 

Supravaginal  Hypertrophy. — This  condition  is  usually  congenital  in 
origin.  As  a  result  the  cervix  descends  and  carries  with  it  the  vaginal 
walls  to  a  point  where  they  may  present  at  the  vulvar  outlet.  The 
process  is  essentially  the  same  as  occurs  in  descent  of  the  uterus. 
(See  page  319.) 

Diagnosis. — The  diagnosis  is  made  by  inspection,  palpation,  and 
the  introduction  of  the  sound,  as  discussed  under  descensus  uteri. 


Fig.  362 


Feminine  pseudohermaphroditism. 


Treatment. — ^The  treatment  is  distinctly  surgical  and  necessitates 
a  high  circular  amputation  of  the  cervix.  When  the  vaginal  walls  are 
relaxed,  an  anterior  and  posterior  colporrhaphy  are  required.  As  a 
final  resort  in  extreme  cases,  the  suggestion  of  Baldy  should  be 
adopted,  that  of  supravaginal  amputation  of  the  uterus  and  anchor- 
ing of  the  stump  to  the  abdominal  wall.    (See  page  331.) 

Infravaginal  Hypertrophy. — Here  the  cervix  is  h\'pertrophied  below 
the  attachment  of  the  vagina.  The  condition  is  congenital  and  is 
rare.  These  cases  are  not  common.  The  elongation  of  the^  cervical 
tissues  may  be  so  great  as  to  cause  the  cervix  to  protrude  from  the 
vulva.    The  diameter  of  the  cervix  is  not,  as  a  rule,  increased. 

The  clinical  significance  of  h^■pertrophy  of  the  vaginal  portion  of 
the  cervix  depends  upon  the  degree  of  elongation.  When  of  moderate 
degree  no  disturbances  arise,  but  when  the  cervix  is  greatly  elongated. 


PROGRESSIVE  TISSUE  CHANGES 


000 


sterility,  interference  with  intercourse  and  with  locomotion  are 
complained  of.  In  event  of  pregnancy  labor  is  retarded  by  the  slow 
dilatation  of  the  cervix. 

Diagnosis. — The  diagnosis  is  made  by  sight  and  touch.  Xo  difficulty 
is  experienced  in  recognizing  the  abnormal  length  of  the  cervix.  An 
uncomplicated  elongation  of  the  cervix  is  distinguished  from  a  prolapsed 
uterus,  with  or  without  elongation  of  the  cervix,  by  noting  the  position 
of  the  fundus  in  a  bimanual  examination. 

Treatment. — (See  Amputation  of  the  Cervix.) 

Fig    363 


Hypertrophic  e 


liuu  ut  the  cer\  ix  with  prolapsus  uteri. 


Subinvolution  of  the  Uterus. — The  physiological  involution  of  the 
uterus  following  labor  and  abortion  may  be  arrested  at  a  point  short 
of  the  norm,  leaving  the  uterus  large  and  heavy.  This  hypertrophy 
may  be  confined  to  the  body  or  to  the  cervix,  but,  as  a  rule,  both  are 
affected.  The  endometrium  commonly  shares  in  the  hypertrophy,  as 
do  also  the  ligamentous  supports  of  the  uterus.    All  of  these  tissues 


556     NUTRITIONAL  DISTURBANCES  OF  THE  GENITAL  ORGANS 

are  congested,  and  there  is  a  tendency  on  the  part  of  the  heavy  uterus 
to  descend  and  to  fall  backward. 

History. — The  history  dates  back  to  a  childbirth  or  abortion.  In 
man}'  instances  it  is  learned  that  the  childbed  period  was  of  unusual 
duration,  that  there  was  evidence  of  a  puerperal  infection,  or  that 
there  were  unrepaired  lacerations.  The  symptoms  above  referred  to 
commonly  take  their  origin  in  these  events. 

Etiology. — 

1.  Septic  infection. 

2.  Lacerations  of  the  cervix. 

3.  Uterine  displacements. 

A  postabortive  or  puerperal  infection  will  usually  check  the  process 
of  involution  in  the  uterus.  A  lacerated  cervix,  j^er  se,  probably  has 
little  influence  in  causing  subinvolution,  but  the  resulting  infection, 
which  so  commonly  follows  lacerations,  has  an  important  bearing. 

Anatomy. — Theilhaber  and  Meir  observed  that  in  childhood  the 
musculature  of  the  uterus  is  to  the  fibrous  tissue  as  2  is  to  1,  in  the 
muciparous  uterus  it  is  as  1  is  to  2,  while  in  the  postclimacteric  period 
the  proportion  is  again  reversed. 

It  is  learned  from  the  observations  of  Pick  and  Anspach  that  the 
elastic  tissues  of  the  uterus  play  an  important  role  in  that  they 
support  the  blood  and  lymph  vessels,  reinforce  the  musculature,  and 
aid  materially  in  the  involution  of  the  uterus.  During  the  first  four 
months  of  pregnancy  the  elastic  tissue  increases  in  amount,  then 
remains  about  stationary  in  the  later  months  of  pregnancy,  and  again 
undergoes  increase  during  the  puerperium.  The  exception  to  this 
rule  is  found  in  the  cervix  when  the  elastic  tissue  goes  on  increasing 
throughout  labor  and  aids  in  the  dilatation  of  labor. 

In  the  subinvoluted  uterus  there  is  a  disproportionate  amount  of 
fibrous  tissue  and  a  lack  of  increase  in  elastic  tissue.  All  this  leads  to 
muscular  insufficiency  with  lack  of  control  over  the  caliber  of  the 
bloodvessels  which  course  through  the  myometrium.  This  constitutes 
the  anatomical  basis  for  hemorrhage  in  subinvolution  of  the  uterus. 

Symptoms. — 

1.  Menstrual  Disorders. —  As  a  rule,  the  menstrual  flow  is  excessive. 
The  explanation  lies  in  muscular  insufficiency  of  the  uterus.  The 
menstrual  periods  are  prolonged  and  the  amount  of  blood  lost  may 
be  two  or  three  times  the  normal  amount. 

2.  Leucorrhea. — In  the  absence  of  a  specific  infection  or  other  causes 
of  leucorrhea,  there  is  a  hypersecretion  from  the  uterus  differing  only 
in  amount  from  the  normal  secretion. 

3.  Sense  of  Weight  in  the  Pelvis.— The  heavy  uterus  and  relaxed 
supports  lead  to  a  sagging  of  the  uterus  and  commonly  to  retroversion. 
The  patient  complains  of  a  feeling  of  heaviness  and  insecurity  in  the 
pelvis. 

4.  Dysmenorrhea. — The  menstrual  periods  are  usually  accompanied 
by  heavy  cramping  pains  in  the  hypogastrium  and  by  backache. 


PROGRESSIVE  TISSUE  CHANGES  557 

Sterility. — While  subinvolution  of  the  uterus  does  not  preclude 
the  possibility  of  childbearing,  it  is  true  that  the  conditions  are  not 
favorable.    This  is  one  explanation  for  the  so-called  "habit  of  abortion." 

The  associated  lesions,  i.  e.,  displacements,  lacerated  perineum,  and 
cystic  degeneration  of  the  ovaries,  give  rise  to  symptoms  which  are  not 
to  be  credited  to  subinvolution  of  the  uterus. 

Diagnosis. — The  diagnosis  is  determined  by  a  consideration  of  the 
history,  by  the  complaints  of  the  patient,  and  by  a  physical  examination. 

Physical  Examination. — Bimanual  examination  reveals  a  uniformly 
enlarged  uterus,  somewhat  soft  in  consistency,  uniform  in  outline, 
freely  movable,  and  not  sensitive  to  pressure.  Downward  and  backward 
displacements  are  common.  Placing  a  sound  in  the  uterus  will  demon- 
strate an  increase  in  size  of  from  one-half  inch  to  an  inch. 

Prognosis. — If  taken  in  the  early  stages  of  its  development,  much 
can  be  done  to  favor  involution,  but  in  the  chronic  stage,  when  hyper- 
plastic changes  have  developed,  there  is  little  hope  of  relieving  the 
condition. 

Treatment. — It  is  important  to  arrest  the  condition  in  the  early 
stages  of  its  development. 

Early  Stage. — To  prevent  permanent  enlargement  of  the  uterus 
the  following  precautions  should  be  taken : 

1.  Prevent  infection  of  the  uterus  by  strict  observance  of  all  rules 
known  to  the  obstetric  art. 

2.  Avoid  keeping  the  parturient  woman  on  her  back  an  undue  length 
of  time. 

3.  Repair  all  lacerations  early. 

4.  Examine  every  woman  at  the  end  of  the  puerperium.  When  the 
uterus  has  failed  to  involute  no  time  should  be  lost  in  the  effort  to 
encourage  full  involution.    The  following  measures  should  be  adopted: 

1.  Repair  of  neglected  lacerations.  This  should  be  done  not  later 
than  ten  to  fourteen  days  after  labor. 

2.  Correct  all  recent  displacements  by  a  properly  fitting  pessary. 

3.  Hot  vaginal  douches  two  or  three  times  a  day. 

4.  The  administration  of  small  doses  of  ergot  or  ergotin  over  a  period 
of  several  weeks. 

5.  Ichthyol  and  glycerin  tampons  introduced  before  going  to  bed 
and  removed  in  the  morning.  These  tampons  to  be  preceded  and 
followed  by  hot  vaginal  douches. 

6.  Discontinue  all  treatments  daring  the  menstrual  period. 

7.  If  there  is  evidence  of  infection  the  uterus  should  under  no  cir- 
cumstances be  curetted. 

8.  It  is  essential  to  look  to  the  general  condition  of  the  individual. 
The  diet  should  be  nutritious  and  the  bowels  regulated  with  saline 
cathartics.    The  patient  should  be  restricted  in  her  exercises. 

9.  The  Xauheim  baths  are  of  great  value  in  the  management  of 
these  cases,  inasmuch  as  they  tend  to  equalize  the  circulation  and 
relieve  passive  congestion  in  the  pelvis.     (See  page  195.) 


558     NUTRITIONAL  DISTURBANCES  OF   THE  GENITAL  ORGANS 

Late  Stage. — All  that  has  been  recommended  for  the  management 
of  subinvolution  in  the  early  stages  applies  to  the  late  stage,  but  with 
less  promise  of  good  results.  When  the  condition  has  become  chronic, 
surgery  must  be  invoked. 

The  following  surgical  procedures  are  applicable: 

1.  Curettage. — It  is  observed  that  curettage  hastens  in^'olution.  This 
should  not  be  done  if  the  uterus  is  infected. 

2.  Amputation  of  the  Cervix . — When  the  cervix  is  elongated,  and 
particularly  when  lacerated  and  eroded,  the  wedge-shaped  amputation 
of  Schroeder  should  be  done. 

3.  Correction  of  uterine  displacements  and  lacerations  of  the  cervix 
and  pelvic  floor. 

4.  Subtotal  hysterectomy  is  indicated  when  the  uterus  is  greatly 
enlarged  and  gives  rise  to  pressure  symptoms  and  hemorrhage.  (See 
page  441.) 

Hypertrophy  of  the  Ovary. — The  size  of  the  ovary  varies  within 
wide  limits,  and  hence  it  is  not  always  possible  to  distinguish  between 
a  normal  ovary  and  one  that  is  hypertrophied.  Hypertrophy  of  the 
ovary  frequently  complicates  uterine  fibroids.  An  hypertrophied 
ovary  measuring  four  inches  in  length  was  removed  by  Webster,  together 
with  a  fibrocystic  tumor  of  the  uterus  which  weighed  eighty-seven 
pounds. 

In  true  hypertrophy  there  is  an  increase  in  the  amount  of  ovarian 
tissue.  This  condition  is  not  to  be  confounded  with  hyperplasia  of 
the  connective-tissue  stroma,  the  result  of  passive  congestion  and 
inflammation.  There  are  no  characteristic  clinical  signs  of  hypertrophy 
of  the  ovary.  Early  puberty,  unusual  sexual  vigor,  and  a  late  menopause 
are  the  usual  clinical  manifestations. 


CHAPTER   XXVI 

new-for:matioxs  of  the  vulva  and  vagixa 

Netv-formatioxs  of  the  Vulva  ^Ialigxaxt  Tumoes  of  the  Vulva 
Benign  Tumors  of  the  Vulva  Cancer  of  the  A'ulva 

Fibroma  Sarcoma  of  the  A'ulva 

Lipoma  Xett-formatioxs  of  the  A'agixa 
Enchondroma  Cysts 

Xeuroma  Fibromyoma 

Sebaceous  Cysts  Carcinoma 

Dermoid  C^^sts  Sarcoma 

Vulvar  Cysts  S^mcytioma  Malignum 

Cysts  of  the  HjTiien  Endothehom 

NEW-FORMATIONS   OF  THE  VULVA 

Benign  Tumors  of  the  Vulva. — Benign  tumors  of  the  vulva  are  of 
rare  occtirrence. 

Fibromata  arise  from  the  subcutaneous  connective  tissue  of  the  labia 
majora  and  minora,  but  rarely  from  the  clitoris.  They  are  slow  in 
their  growth,  and  firm,  round,  and  sharply  circumscribed.  The  over- 
lying skin  is  not  adherent  to  the  tumor.  They  are  known  to  grow  to 
the  size  of  the  patient's  head  and  to  hang  by  a  pedicle  to  the  level  of 
the  knees.  The  microscope  shows  the  tumor  to  be  composed  of  con- 
nective tissue  intermixed  with  a  limited  amount  of  smooth  muscle 
fiber.   Cystic  degeneration  and  calcareotis  deposits  have  been  described. 

Lipomata  rise  from  the  subctitaneous  fat  of  the  mons  Veneris  and 
labia  minora.  They  are  not  so  frequently  found  as  are  fibromata.  They 
are  usually  circumscribed,  soft  in  consistency,  sometimes  apparently 
fluctuating,  and  are  attached  either  by  a  broad  base  or  by  a  pedicle. 
The  author  has  found  only  22  cases  of  lipoma  of  the  vulva  in  the 
literature.  They  have  been  seen  from  the  fifth  month  of  infancy  to  the 
fifty-first  year. 

Enchondroma  has  not  yet  been  fully  established. 

Neuroma  has  been  described  as  a  sensitive  papilla  or  wart,  though 
the  description  leaves  some  doubt  as  to  its  identity.  Peckham  described 
a  cyst  of  the  clitoris  weighing  60  grams  and  filled  with  a  chocolate- 
colored  fluid. 

Sebaceous  cysts  are  fotmd  in  the  labia,  at  the  base  of  the  prepuce,  and 
at  the  base  of  the  hymen.  They  appear  in  the  form  of  small,  yellowish, 
semitransparent  elevations  filled  with  sebaceous  material.  Small,  soft- 
walled  cysts,  lying  at  the  free  margin  of  the  hymen,  may  be  regarded  as 
lymph  cysts. 


560 


NEW-FORMATIONS  OF  THE   VULVA   AND   VAGINA 


Dermoid  Cyst  of  the  vulva  is  of  rare  occurrence. 

Vulvar  Cysts  have  Httle  cHnical  significance.  An  accompanying 
pruritus  may  disclose  their  presence. 

Cysts  of  the  Hymen. — Little  is  known  of  cysts  of  the  h.ymen.  Wenkel 
made  the  first  report  of  these  cysts  in  1883.  Palm  described  one  measur- 
ing 8  cm.  in  diameter.    The  average  diameter  is  about  1  cm.    Many 

Fig.  364 


Pedunculated  fibroma  of  the  vulva. 


do  not  exceed  1  mm.  in  diameter.  They  are  usually  congenital,  though 
they  may  not  be  observed  until  late  years.  One  or  more  cysts  are 
located  near  the  free  margin  of  the  hymen.  These  various  sources 
explain  the  presence  of  a  variety  of  epithelium  lining  the  cyst  cavity. 
As  a  rule,  the  epithelium  is  squamous  and  stratified,  but  is  occasionally 
cylindrical,  and  in  a  few  instances  endothelium  is  found. 


NEW-FORMATIONS  OF  THE  VULVA 


561 


The  origin  of  the  cysts  of  the  hymen  is  in  many  cases  the  epithelial 
projections.  These  projections  become  constricted  off  and  form  the 
epithelial  wall  of  a  space  which  fills  with  serum.  A  few  cases  apparently 
arise  from  Gartner's  duct,  from  dilated  lymph  spaces,  and  from  retention 
of  the  secretions  of  sebaceous  glands. 

In  a  valued  original  communication  on  the  "Anatomy,  Pathology, 
and  Development  of  the  Hymen"^  G.  Gelhorn  presents  numerous 
lesions  of  the  hymen  not  generally  recognized. 


Fig.  3C5 


Fibromyoma  of  the  posterior  u  all  (jl  the 


Surface  ulcerated. 


Tumors  of  the  hymen  are  rare.  Gelhorn  finds  17  cases  of  hymeneal 
cysts  in  the  literature,  2  cases  of  polypi,  and  1  of  angioma.  Sanger 
reported  a  case  of  primary  sarcoma  of  the  hymen.  As  yet  no  case  of 
primary  carcinoma  of  the  hymen  has  been  reported. 

Treatment.- — All  benign 'tumors  of  the  vulva  should  be  excised  and 
the  wound  closed  with  silkworm-gut.     The  sutured  wound  is  covered 


36 


Amer.  Jour.  Obstet.,  August,  1904. 


562 


NEW-FORMATIONS  OF  THE  VULVA  AND  VAGINA 


with  a  dressing  of  sterile  gauze,  held  in  place  by  a  T-binder.     The 
sutures  should  be  removed  on  the  seventh  day. 

Cancer  of  the  Vulva. — The  vulva  is  strangely  exempt  from  infection 
and  malignant  degeneration.  In  1147  cancers  of  the  female  genitalia 
Schwarz  found  30  to  be  primary  in  the  vulva.     Wenkel  tabulated  the 

Fia.  366 


Carcinoma  of  the  vulva.    A  cauliflower  growth  two  inches  in  diameter  was  located  in  the  right  labium 
majorum.     The  tumor  was  friable  and  bled  freely  to  the  touch. 


report  of  54  cases,  in  which  he  found  6  before  the  age  of  forty,  16  between 
forty  and  fifty,  20  between  fifty  and  sixty,  and  20  over  sixty  years 
of  age. 

The  site  of  predilection  is  the  outer  skin  surface  of  the  labia  majora; 
less  frequent  points  of  invasion  are  the  frenum,  clitoris,  Bartholinean 


NEW-FORMATIONS   OF   THE   VULVA 


563 


glands,  anterior  and  posterior  commissure,  and  urethral  opening.    The 
labia  minora  are  seldom  a  primary  site. 

The  lesion  is  characterized  by  superficial  infiltration,  by  ulceration, 
and  by  early  involvement  of  the  inguinal  glands.  The  growth  may  be 
diffuse  or  circumscribed.  The  circumscribed  growths  rarely  fail  to  rise 
above  the  level  of  the  surface  of  the  skin.  They  are  commonly  round 
or  oval,  and  the  surface  smooth,  nodular,  or  papillary.  They  may 
grow  to  the  size  of  a  man's  fist.  At  first  firm  in  consistency,  sooner  or 
later  they  disintegrate  and  form  more  or  less  superficial  ulcers.  The 
diffuse  form  may  not  be  evident  to  the  naked  eye,_and  is  recognized 
by  its  rigid,  firm  feel.     Superficial  ulceration  is  usually  not  long  in 


Fig.  367 


Early  carcinoma  of  the  vulva,  confined  to  the  clitoris.     (Martin.) 


appearing.  There  is  nothing  uncommon  in  the  appearance  of  the 
ulcer;  the  base  is  uneven,  bleeding  freely  to  the  touch,  and  is  covered 
with  a  purulent,  foul-smelling  secretion;  the  margins  of  the  ulcer  are 
irregular,  hard,  and  elevated.  In  advanced  cases  the  ulceration  may 
extend  to  deep  crater-like  excavations,  with  markedly  infiltrated  borders 
(Fig.  366). 

Schwarz  found  the  inguinal  glands  infiltrated  with  cancer  cells 
eleven  times  in  twenty-three  cases.  The  rate  of  growth  is  often  slow. 
The  direction  to  which  the  growth  extends  varies.  Usually  the  extension 
is  to  the  vagina  and  from  the  A'agina  to  the  rectum,  bladder,  and  pelvic 
connective  tissue.  In  not  a  small  percentage  of  cases  the  opposite 
labium  is  invaded  (contact  metastasis). 


564  NEW-FORMATIONS  OF  THE  VULVA  AND   VAGINA 

The  microscopic  characters  of  vulvar  carcinoma  differ  somewhat 
from  those  of  cancer  of  the  vagina  and  cervix.  There  is  an  unusual 
tendency  on  the  part  of  the  epithelial  projections  to  branch.  Cancer 
pearls-  are  said  to  be  relatively  rare,  although  in  two  specimens,  one 
removed  by  Dr.  Reuben  Peterson  and  the  other  by  Dr.  J.  Clarence 
Webster,  the  author  found  an  unusual  number  of  cancer  pearls.  The 
extension  of  the  cancer  cells  along  the  lymphatics  gives  the  appearance 
of  veins  of  marble. 


Ljinphadenoma  of  the  vulva.     (Hertzler.) 


Cancer  of  the  glands  of  Bartholin  is  rare.  The  gland  may  assume  the 
size  of  a  man's  fist,  become  hard  and  nodular,  with  a  movable,  normal 
appearing  overlying  skin.  The  diagnosis  without  the  aid  of  the  micro- 
scope is  hardly  possible.  The  lesions  to  be  considered  in  making  a  diag- 
nosis are  the  benign  new-formations  (lipoma,  fibroma),  with  ulcerated 
surface,  ulcus  rodens,  tuberculosis,  sj'philis,  and  elephantiasis.  In  making 
the  diagnosis,  one  must  rely  upon  the  age  of  the  individual,  the  general 
effect  upon  the  system,  early  and  superficial  ulceration,  involvement 
of  the  inguinal  glands,  and  above  all,  upon  the  microscopic  examination 
of  an  excised  piece  of  the  tumor.  The  prognosis  is  relatively  good. 
Schwarz  saw  ten  recoveries  in  twenty-three  cases. 

Treatment. — Cancer  of  the  \Tilva  requires  early  and  radical  removal. 
Not  only  should  the  gro-^th  be  widely  excised,  but  the  inguinal  glands 
should  also  be  removed.     The  loose  texture  of  the  structures  of  the 


NEW-FORMATIONS  OF  THE  VULVA 

Fig.  369 


565 


Early  adenocarcinoma  of  the  vulva,  limited  to  the  left  lesser  labium.      (Hurdon.) 

Fig.  370 


Extirpation  of  the  vulva.     Lines  of  initial  incisions. 


566 


NEW-FORMATIONS  OF  THE  VULVA   AND   VAGINA 


viih'a  permits  of  ready  approximation  e\-eii  after  a  large  area  is 
removed.  Fig.  370  presents  an  outline  of  the  area  to  be  resected  in 
advanced  cases. 

Fig.  371 


Carcinoma  of  the  ^n.lh-a.      (Hertzler.) 

Palliative  Treatment. — Following  the  removal  of  the  growth  and 
in  all  inoperable  cases,  the  .r-rays  should  be  applied  at  intervals.  When 
the  growth  is  too  far  advanced  to  permit  of  removal,  the  cancerous  tissue 
should  be  deeply  cauterized  and  a  moist  dressing  of  the  following 
solution  applied: 

I^ — Glycerin giij 

Water gviij 

Formalin Vf[xv 

A  vulvar  pad  is  saturated  with  this  solution  and  held  in  place  by 
a  T-binder.  Frequent  vulvar  douches  of  formalin  (1  to  4000)  should 
be  given. 


NEW-FORMATIONS  OF  THE  VAGINA  567 

Prognosis. — Taussig  compares  the  prognosis  of  cancer  of  the  uterus 
with  cancer  of  the  vulva,  and  reveals  the  interesting  fact  that  while 
it  is  generally  true  that  superficial  cancers  give  a  more  favorable  prog- 
nosis than  do  the  deep-seated  cancers,  the  reverse  is  true  of  genital 
cancers  in  women.  He  gives  the  percentage  of  cures  in  cancer  of 
the  body  of  the  uterus  as  80,  in  cancer  of  the  cervix  between  20 
and  30,  and  in  cancer  of  the  vulva  as  12.  He  accounts  for  the  high 
mortality  in  cancer  of  the  vulva  by  the  advanced  age  of  the  patient, 
(average  sixty  to  sixty-five  years),  early  metastasis  to  tributary  lymph 
glands,  and  the  proximity  of  the  cancer  to  the  urethra  and  pubic  arch. 
In  cancer  of  the  vulva,  as  in  cancer  elsewhere  in  the  body,  the  secret  of 
successful  results  lies  in  early  diagnosis  and  in  early  operation. 

Sarcoma  of  the  Vulva. — This  is  a  very  rare  lesion.  Hunter  Robb 
has  described  a  m}'xosarcoma  of  the  clitoris.  Melanotic  sarcoma  of 
the  vulva  is  an  intensely  malignant  growth.  Bailley  reported  a  melano- 
sarcoma  in  a  woman,  aged  seventy- two  years. 

Recurrence  is  almost  certain.  ^Mueller  removed  from  the  labium 
minor  a  melanosarcoma  as  large  as  a  walnut.  There  was  no  recurrence 
until  the  end  of  three  years.  Fisher  reports  a  recovery  in  a  woman, 
aged  fifty-six  years,  from  whom  a  melanosarcoma  the  size  of  a  walnut 
was  removed  from  the  labium  major. 

Treatment. — (See  Cancer  of  the  Vulva.) 


NEW-FORMATIONS  OF  THE  VAGINA 

Cysts  of  the  Vagina. — Cysts  of  the  vagina  are  not  of  great  rarity. 
Xeugebauer  found  .36  cases  in  600  observations  (Fig.  372). 

Histogenesis. — The  fact  that  the  epithelial  lining  of  the  cysts  varies 
in  form  suggests  various  origins,  ^'^eit  believes  them  to  develop  from 
remains  of  the  Wolffian  ducts.  The  ducts  of  Gartner  do  not  ordinarily 
continue  below  the  vault  of  the  vagina,  but  instances  are  known  in 
which  they  extended  as  far  as  the  urethral  opening  along  the  lateral 
and  anterior  walls  of  the  vagina.  In  these  ducts  muscle  fibers  and 
cylindrical  epithelium  are  observed,  and  it  is  believed  by  some  that 
cysts  located  in  the  sides  or  in  the  anterior  wall  of  the  vagina,  and 
containing  muscle  fibers  and  epithelium,  arise  from  the  ducts  of 
Gartner.  As  further  evidence  of  this  origin,  may  be  mentioned  their 
occasional  elongated  form  with  their  long  axis  in  a  line  corresponding 
to  the  long  axis  of  the  vagina.  Still  more  significant  is  the  rosary-like 
arrangement  of  two  or  more  cysts  along  the  line  of  Gartner's  duct. 

Preuschen  suggests  that  the  origin  of  vaginal  cysts  may  be  the  glands 
of  the  vagina.  Cysts  lying  in  the  posterior  wall  of  the  vagina  are  thus 
explained.  They  are  regarded  as  retention  cysts.  Davidson  holds 
that  the  glands  of  the  vagina  are  purely  misdevelopments.  Those  in 
the  upper  segment  of  the  vagina  are  misplaced  from  the  cervix  and 
maintain  the  character  of  cervical  glands,  while  those  in  the  lower 
segment  of  the  vagina  are  from  the  vulva.     Retention  cysts  arising 


568  NEW-FORMATIONS  OF  THE  VULVA   AND   VAGINA 

from  these  glands  are  usually  multiple,  of  small  size,  and  lined  -with 
a  single  layer  of  columnar  epithelium.  Cysts  may  arise  from  partial 
adhesion  of  the  folds  of  vaginal  mucous  membrane  inclosing  spaces 
lined  with  flat  epithelium. 

Fig.  372 


Cyst  of  the  anterior  wall  of  the  vagina.  A  thin-walled,  translucent  cyst  protrudes  from  the  vulva. 
Such  a  growth  may  be  mistaken  for  an  inverted  uterus  or  a  complete  prolapsus  uteri.  The  cyst 
fluctuates,  there  are  no  tubal  or  ceri-ical  openings,  and  the  uterus  is  found  in  its  normal  position 
by  a  recto-abdominal  examination. 

-Freund  believes  that  cysts  of  the  vagina  arise  from  the  rudimentary 
ducts  of  Miiller.  Furthermore,  it  is  apparent  that  the  lymph  spaces 
may  distend  into  cysts  lined  with  endothelium. 

Cysts  of  the  vagina  are  rarely  of  large  size,  ranging  from  that  of  a 
pinhead  to  a  hazel-nut.  In  exceptional  cases  they  are  as  large  as  a 
child's  head.  They  are  slow  in  growth.  The  sites  of  election  are  the 
anterior  and  lateral  walls,  rarely  the  posterior  wall  of  the  vagina.  They 
lie  immediately  underneath  the  epithelium  and  bulge  into  the  vagina. 


NEW-FORMATIONS  OF  THE  VAGINA  569 

The  consistency  is  elastic  and  the  contents  clear,  watery,  or  mucoid. 
Occasionally  the  contents  are  milky  from  the  presence  of  degenerated 
epithelium;  sometimes  chocolate  colored  from  admixture  with  blood. 
Cheron  reports  the  presence  of  a  stone  in  a  cyst.  Cholesterin  crystals 
are  occasionally  found.  As  a  rule,  the  cysts  are  simple,  but  they  may 
be  multilocular.  The  cyst  wall  is  composed  of  fibrous  tissue,  occasion- 
ally mingled  with  some  muscle  fibers.  The  inner  surface  is  generally 
lined  with  a  single  layer  of  cylindrical  epithelium,  but  sometimes  with 
several  layers  of  cylindrical  or  flat  epithelium.  It  is  seldom  that  endo- 
thelial cells  are  found.  They  are  not  usually  of  clinical  interest,  but 
are  known  to  interfere  with  sexual  intercourse  and  with  childbirth,  and 
have  been  mistaken  for  prolapsus  uteri  and  inversion  of  the  uterus. 

Treatment. — The  treatment  of  cysts  of  the  vagina  is  surgical,  and 
consists  of  partial  or  complete  removal  of  the  sac. 

Partial  Removal  of  the  Sac. — Unless  the  cyst  is  superficial  and 
small,  no  attempt  should  be  made  to  remove  the  entire  sac  for  fear 
of  injury  to  the  bladder,  rectum,  ureter,  or  peritoneum.  When  the 
dissection  is  deep  there  is  great  danger  from  troublesome  bleeding. 

Technic  of  Operation. — The  patient  is  placed  in  the  lithotomy  position 
and  the  cyst  exposed  by  specula. 

Step  1. — The  cyst  is  grasped  at  its  apex  by  bullet  forceps,  and  a 
second  pair  is  made  to  grasp  the  cyst  wall  a  half  inch  removed  from 
the  other  forceps.  The  sac  is  then  opened  with  a  knife  and  its  contents 
emptied.  Through  the  opening  the  examining  finger  explores  the 
cavity  of  the  cyst  and  notes  its  relations  to  surrounding  structures. 

Step  2. — The  incision  in  the  sac  wall  is  extended  to  the  limits  of  the 
sac,  and  each  half  of  the  sac  wall  is  excised  to  the  level  of  the  vaginal 
wall. 

Step  3. — The  margins  of  the  cyst  wall  are  stitched  to  the  cut  edges 
of  the  vaginal  wall  with  chromic  catgut.  The  cavity  of  the  cyst  is 
then  packed  with  iodoform  gauze  and  a  sterile  dressing  applied  and 
held  in  place  by  a  T-binder.  The  gauze  is  removed  at  the  end  of 
forty-eight  hours  and  the  open  wound  kept  clean  by  frequent  antiseptic 
irrigations  until  healing  is  complete. 

Complete  Removal  of  the  Sac.^ — Only  small  and  superficial  cysts 
should  be  wholly  removed.  The  cyst  is  removed  by  incising  the  vaginal 
wall  over  the  sac  and  dissecting  the  sac  en  masse  from  the  surrounding 
structures;  then  closing  the  wound  with  catgut. 

Fibromyoma  of  the  Vagina. — Richard  R.  Smith  collected  101  cases 
from  the  literature.  They  commonly  occur  between  the  ages  of  twenty 
and  forty  years,  and  have  been  observed  as  early  as  one  and  a  half 
years  and  as  late  as  seventy-eight  years.  The  largest  one  recorded 
weighed  ten  pounds.  They  .are  usually  round  and  attached  by  a 
broad  base  or  pedicle.  The  surface  is  smooth  or  nodular,  and  is  covered 
with  vaginal  mucous  membrane.  They  are  seldom  of  soft  consistency. 
Their  origin  is  in  the  submucous  connective  tissue.  They  are  rarely 
multiple,  and  are  generally  located  in  the  anterior  wall  of  the  vagina. 
The  usual  forms  of  degeneration  common  to  fibroids  are  possible.    The 


570 


NEW-FORMATIONS  OF   THE   VULVA   AND    VAGINA 


diagnosis  is  not  difficult.  A  soft  fibroid  might  be  mistaken  for  a  cyst, 
a  cystocele,  or  a  rectocele.  The  bluish,  semitransparent  color  of  the 
cyst  is  of  special  significance. 

Treatment. — The  treatment  consists  in  the  removal  of  the  tumor. 
Caution  must  be  exercised  for  fear  of  injuring  the  bladder,  rectum, 
ureter,   or  peritoneum. 

The  vaginal  wall  is  incised  over  the  tumor;  the  tumor  enucleated 
with  a  blunt  dissector,  all  bleeding-points  secured  by  ligatures,  the 
redundant  vaginal  walls  excised,  and  the  wound  closed  with  chromic 
catgut. 


Fig.  373 


Fig.  374 


Enucleation  of  a  vaginal  cyst.  Vertical  incLsion 
made  through  the  vaginal  wall.  (Modified  from 
Ashton.) 


Step  2.     Vaginal  wall  reflected  from  the   cyst 
by  a  dissector.     (Modified  from  Ashton.) 


Carcinoma  of  the  Vagina. — Etiology. — Less  than  1  per  cent,  of  all 
cancers  in  women  are  of  vaginal  origin  (Williams,  Bristol).  Kiistner 
collected  22  cases  of  primary  cancer  of  the  vagina,  and  estimates  that 
about  0.02  per  cent,  of  cancers  of  the  genital  tract  arise  primarily  in 
the   vagina. 

As  a  rule,  primary  carcinoma  of  the  vagina  arises  between  the  ages 
of  fifty  and  sixty;  two  cases  are  reported  at  twenty  years  of  age.  Child- 
bearing  does  not  influence  the  development  of  the  growth,  and  heredity 
plays  a  minor  role.  A  number  of  cases  have  been  recorded  in  which 
ill-fitting  pessaries  have  caused  ulceration  and  eventually  malignant 


NEW-FORMATIONS  OF  THE   VAGINA 


571 


degeneration.  Prolapse  of  the  vaginal  walls  subjects  the  vagina  to 
mechanical  insults,  and  upon  the  injured  surface  a  carcinoma  may  be 
developed  (Fig  377). 

Anatomical  Diagnosis. — In  123  cases  71  were  found  on  the  posterior 
vaginal  wall,  13  on  the  lateral  walls,  and  16  were  annular.  The  growth 
may  be  papillary,  nodular,  or  infiltrating.  To  the  unassisted  eye  cancer 
of  the  vagina  usually  presents  a  thickened,  ulcerated  area.  The  margins 
are  irregular,  hard,  and  elevated.  The  base  of  the  ulcer  is  uneven, 
bleeds  freely  on  handling,  and  is  covered  with  a  foul-smelling  secretion. 


Fig.  375 


Fig.  376 


Step  3.  Part  of  cyst  wall  excised.  The  cyst 
extends  too  deeply  into  the  underlying  struc- 
tures to  permit  of  complete  enucleation. 


Step  4.  Sutures  placed  for  closure  of  the  cavity. 
When  the  cyst  is  not  wholly  removed  the  cavity 
should  be  packed  with  iodoform  gauze  and  left 
open  to  heal  by  granulation  tissue. 


Surrounding  the  vagina  the  tissues  show  an  inflammatory  reaction, 
and  secondary  nodules  "may  be  seen  distributed  over  the  surface. 
The  growth  rarely  attains  the  size  of  a  man's  fist.  Extension  into  the 
paravaginal  tissue  is  rapid.  Reaching  the  lymph  spaces  of  the  para- 
vaginal connective  tissue,  the  cancer  cells  are  rapidly  carried  to  the 
retroperitoneal  glands.  The  inguinal  glands  are  enlarged  when  the 
lower  segment  of  the  vagina  is  invaded.  As  a  rule,  the  uterus  is  not 
invaded  so  early  as  the  vulva,  and  metastasis  to  distant  organs  is  late. 
The  microscope  shows  nothing  unusual.  The  tumor  is  a  flat-cell 
growth,  the  cells  are  arranged  in  nests,  and  contain  many  pearls. 


572  NEW-FORMATIONS  OF  THE  VULVA  AND   VAGINA 

Clinical  Diagnosis.— The  lesion  may  go  unrecognized  until  far 
advanced.  As  with  cancer  of  the  uterus,  all  symptoms  may  be  wanting 
until  there  is  ulceration  and  sloughing  of  the  growth.  Hemorrhage, 
pain,  and  a  foul-smelling  discharge  are  the  cardinal  symptoms,  but 

Fig.  377 


Primary  carcinoma  of  the  vagina.    On  the  posterior  wall  of  the  vagina  is  an  irregular  infiltrated  area, 

friable  and  bleeding. 


they  do  not  differ  in  any  manner  from  the  same  group  found  in  cancer 
of  the  vulva  or  uterus.  Pain  is  rarely  present  until  the  gro-«i;h  has 
extended  into  the  paravaginal  tissue,  and  the  absence  of  pain  is  a  marked 
feature  in  the  early  stage. 


NEW-FORMATIONS  OF  THE  VAGINA  573 

Stenosis  .of  the  vagina  may  hide  a  growth  lying  above  the  point 
of  constriction,  and  render  the  early  diagnosis  perplexing. 

Secondary  cancer  of  the  vagina  is  of  frequent  occurrence.  Cancer 
of  the  cervix  is  especially  liable  to  extend  to  the  vagina,  but  normal 
tissue  may  intervene  between  the  primary  growth  in  the  cervix  and 
the  secondary  gro-v\i:hs  in  the  vagina.  Cancer  of  the  bladder  and  rectum 
rarely  invade  the  vagina.  Metastatic  growi:hs  from  the  ovary  are 
seldom  observed  in  the  vagina. 

Wahn,  Fisher,  and  Kalkenbach  report  implantations  of  cancer  cells 
upon  eroded  surfaces  in  the  vagina  through  the  medium  of  a  leucorrheal 
discharge.  The  secondary  growths  take  the  same  histological  forms 
as  the  primary  growth.  The  average  duration  of  primary  cancer  of 
the  vagina  is  said  to  be  sixteen  months,  but  it  may  last  several  years. 

DifEerential  Diagnosis. —  Decubitus  ulcers  caused  by  ill-fitting  pessaries 
may  be  mistaken  for  carcinoma,  and  have  been  known  to  be  its  starting- 
point.  The  hard,  elevated  margins,  friable  and  bleeding  when  handled, 
are  distinctive  of  malignancy.  When  doubt  exists,  a  microscopic 
examination  of  an  excised  piece,  or  scrapings  from  the  suspected 
portion,  will  determine  the  diagnosis. 

Syphilitic  and  tuberculous  ulcers  of  the  vagina  are  recognized  by  the 
clinical  history,  by  evidences  of  lesions  elsewhere  in  the  body,  and  by 
microscopic  examination  of  excised  pieces.  Friability  and  bleeding 
of  the  suspected  tissue  are  suggestive  of  carcinoma. 

Treatment. — Early  and  complete  removal  of  the  growth  is  the  only 
effective  treatment. 

Radical  Treatment. — When  the  growth  is  limited  in  extent  only 
a  part  of  the  vaginal  wall  need  be  sacrificed,  but  when  the  growth  is 
extensive  it  may  require  the  extirpation  of  the  entire  vagina. 

Removal  of  the  growth. 

Step  1. — The  tumor  is  exposed  by  specula.  An  incision  is  made 
far  outside  the  infiltrated  area  and  around  the  entire  circumference  of 
the  growth.  The  tumor  is  then  pulled  forward  by  bullet  forceps  and 
dissected  from  the  underlying  tissues.  So  far  as  possible  a  blunt  dissector 
should  be  used. 

Step  2. — The  wound  is  then  united  by  sutures  of  chromic  catgut. 
When  the  bladder  or  rectum  are  invaded  the  incision  must  be  carried 
through  these  structures.  The  inguinal  glands  should  be  removed  in 
all  cases.  After  placing  the  sutures  the  vagina  is  packed  with  iodoform 
gauze  and  a  T-binder  adjusted.  The  gauze  is  removed  at  the  end  of 
forty-eight  hours  and  daily  antiseptic  vaginal  douches  are  then  given. 
When  the  base  of  the  bladder  has  been  excised  a  self-retaining  catheter 
should  be  worn  for  ten  days. 

Total  Extirpation  of  the  Vagina. — There  is  little  encouragement  in 
performing  such  an  extensive  operation  as  the  removal  of  the  entire 
vagina,  because  when  this  is  required,  the  disease  has  advanced  beyond 
hope  of  radical  removal. 

Palliative  Treatment. — When  the  disease  is  inoperable,  palliative 
measures  should  be  resorted  to.    These  consist  in  thoroughly  curetting 


574  NEW -FORM  AT  IONS  OF   THE   VULVA   AND   VAGINA 

the  cancerous  friable  tissue,  cauterizing  the  surface,  and  applying 
acetone.  The  treatment  is  that  advised  for  inoperable  cancer  of  the 
cervix.     (See  Cancer  of  the  Uterus.) 

The  a-rays  are  of  value  in  inoperable  cases,  and  should  also  be  applied 
in  all  cases  following  operation. 

Sarcoma  of  the  Vagina. — Sarcoma  of  the  vagina  is  found  in  all  ages, 
from  the  first  to  the  eighty-second  year.  Six  so-called  congenital  cases 
are  reported.  Of  40  cases  reported  by  Williams,  36  occurred  before 
fifteen  years  of  age. 

The  growth  is  usually  polypoid,  of  a  yellowish-gray  or  chocolate 
color.  Rarely  is  there  a  diffuse  infiltration  of  the  vaginal  walls,  the 
surrounding  structures  being  early  invaded.  Distinct  metastasis  is 
late,  and  does  not  often  occur.  There  is  a  tendency  to  early  necrosis 
of  the  tumor  mass,  together  with  infection  of  the  necrotic  mass  by 
pyogenic  microorganisms,  leading  to  cystitis,  pyonephritis,  and  peri- 
tonitis. Late  in  life  sarcoma  is  usually  smooth  rather  than  rough  and 
polypoid  as  in  early  life. 

Histologically,  the  growth  is  demonstrated  to  be  a  fibrosarcoma, 
myxosarcoma,  round-cell  or  spindle-cell  sarcoma,  or,  finally,  a  melano- 
sarcoma. 

The  diagnosis  of  sarcoma,  apart  from  carcinoma,  cannot  be  made 
without  the  aid  of  the  microscope. 

Treatment. — (See  Cancer  of  the  Vagina,  page  573.) 

Syncytioma  Vaginae. — Syncytioma  malignum  (or,  as  better  named, 
chorio-epithelioma  malignum)  occurs  with  relative  frequency  as  a 
secondary  growth  in  the  vagina. 

Schmidt  lately  reported  two  cases  of  primary  growths  in  the  vagina. 
In  both  cases  the  uterus  remained  normal. 

Kiible  removed  a  primary  syncj'tial  growth  from  the  vagina,  and 
in  twenty  days  it  had  recurred. 

All  newgrowths  of  the  vagina  developing  weeks  and  months  after 
labor  should  be  incised  and  examined,  with  special  regard  for  malignant 
proliferation  of  the  syncytium.  To  the  unaided  eye  the  tumor  is 
usually  round  and  elevated.  It  is  of  a  bluish  color.  Ulceration  is 
rare.  On  cross-section  the  tumor  is  exceedingly  bloody,  and  may 
resemble  a  blood-clot.     (See  page  174.) 

Endothelioma  of  the  Vagina. — Endothelioma  of  the  vagina  is  an 
exceptional  growth.  The  first  case  was  reported  by  Klein.  By  the 
naked  eye  the  growth  cannot  be  distinguished  from  a  carcinoma. 
Microscopically  the  tumor  is  found  to  be  composed  of  cells  resembling 
flat  epithelium,  arranged  in  a  thick  mesh-work  of  connective  tissue. 
The  cells  arise  from  the  endothelium  of  the  blood  or  lymph  spaces. 
In  distribution  they  resemble  veins  of  marble. 

Treatment. — (See  Cancer  of  the  Vagina,  page  573.) 


CHAPTER  XXVII 
FIBRO]^n^O^IA  OF  THE  UTERUS 

Etiology  ,  Treatment 

Histogenesis  ,  Opeeatioxs  for  Uterine  Fibroids 


Anatomical  Diagnosis 
Recurrence 
Microscopic  Diagnosis 
Adenofibromyoma  Uteri 
Degeneration  of  Fibroids 
Clinical  Characteristics 
Clinical  Diagnosis 
Differential  Diagnosis 
Effect  on  Neighboring  Organs 


Vaginal  ^lyomectomy 
Vaginal  Hysterotomy 
Vaginal  Celiotomy 
Abdominal  AU^omectomy 
Hysteromyomectom}" 
Vaginal 
Abdominal 
Fibroids  Complicating  Pregnancy, 
Labor,  and  Puerperium 


Etiology. — But  little  is  known  of  the  essential  cause  of  uterine 
fibroids.  Certain  factors  are  known  to  influence  their  origin  and 
development,  and  will  be  briefly  discussed. 

1.  Heredity. — Heredity  has  been  much  referred  to  as  a  predisposing 
cause  of  uterine  fibroids.  While  there  are  families  in  which  two  or 
more  members  are  known  to  have  fibroid  tumors  of  the  uterus,  the 
influence  of  heredity  is  not  to  be  overestimated.  Engstrom,  in  flve 
hundred  and  thirty  cases  of  uterine  fibroids,  found  a  similar  lesion  in 
the  mother  or  sisters  thirteen  times.  It  has  been  stated  that  myo- 
matous patients  come  of  large  families.  In  the  experience  of  Roger 
Williams  they  averaged  8.1  members  each. 

2.  Age. — The  usual  time  of  occurrence  is  during  the  period  of  sexual 
maturity.  Fibroids  of  the  uterus  are  rarely  found  before  puberty, 
though  it  is  highly  probable  that  most,  if  not  all,  of  these  growths  are 
of  congenital  origin.  They  occur  with  greatest  frequency  between  the 
ages  of  thirty  and  forty,  and  are  rarely  known  to  arise  after  the  meno- 
pause. Miller  reported  299  cases  of  uterine  fibroids,  of  which  number 
120  were  observed  after  forty-five  years  of  age.  Of  the  1762  cases  col- 
lected by  Roger  Williams,  26  were  under  twenty  years  of  age.  Gusserow 
reported  1  case  ten  years  of  age.  Pick  described  a  fibroid  of  con- 
genital origin.  Cavaillou  reports  one  weighing  3  kilograms  in  an  infant 
three  years  of  age.  At  the  other  extreme  of  life  is  a  submucous  myoma 
at  ninety-two  years  of  age  (Van  Rensselaer)  and  a  calcified  myoma  at 
eighty-six  (Wright).  It  is  evident  from  the  study  of  statistics  that  fibro- 
myomata  are  prone  to  arise  at  a  time  when  the  sexual  functions  are 
waning. 

3.  Civil  State. — It  has  been  stated  that  fibroids  of  the  uterus  are 
especially  liable  to  occur  in  women  who  have  not  borne  children  and 
are  not  married.    The  number  of  children  born  to  mvomatous  women 


576  FIBROMYOMA  OF  THE  UTERUS 

is  below  the  average,  while  abortions  are  relatively  common  among 
them.  The  average  number  of  children  born  of  myomatous  women 
is  estimated  at  2.5,  as  compared  with  the  usual  number  of  4.5.  Thirty 
per  cent,  of  myomatous  women  are  sterile  as  opposed  to  10  per  cent, 
of  sterility  in  general.  On  the  other  hand,  sexual  excesses  are  said  to 
favor  the  growth  of  uterine  myomata. 

4.  Race. — The  negress  is  generally  regarded  as  preeminently  sus- 
ceptible to  uterine  fibroids.  This  is  denied  by  Kelly  and  Williams, 
of  Johns  Hopkins  University,  where  there  is  abundant  opportunity 
to  make  reliable  observations.  In  357  cases  reported  by  Williams, 
fibroids  were  only  2  per  cent,  more  frequent  in  the  colored  race.  They 
are  said  to  be  unknown  among  savages. 

5.  Frequency. — Boyle  holds  that  20  per  cent,  of  women  who  reach 
thirty-five  years  of  age  have  fibroids  of  the  uterus,  while  Klobs  affirms 
that  40  per  cent,  of  women  who  reach  fifty  years  of  age  have  fibroids 
of  varying  size  and  number.  The  lesion  is  often  overlooked  even  in 
postmortem  examinations.  Of  all  non-malignant  tumors  uterine 
myomata  are  by  far  the  most  common.  Roger  Williams  estimates 
that  10  per  cent,  of  all  tumors  in  women  are  uterine  fibroids. 

Influence  of  Menstruation,  Pregnancy,  and  the  Climacterium  upon 
Fibromyomata. — 1.  Menstruation. — Menstruation  is  accompanied  by 
a  slight  enlargement  and  softening  of  uterine  fibroids,  due  to  increased 
vascularization.  Near  the  end  of  the  menstrual  flow  the  tumor 
reassumes  its  normal  proportions. 

2.  Pregnancy. — Pregnancy  is  accompanied  by  a  rapid  increase  in 
the  size  of  the  tumor.  There  is  a  corresponding  softening  of  the  growth. 
Such  rapidly  growing  fibroids  are  prone  to  become  incarcerated  and  to 
seriously  interfere  with  pregnancy.  Simultaneous  with  the  involution 
of  the  uterus  in  the  puerperium  there  is  sometimes  a  rapid  decrease  in 
the  size  of  the  tumor.  They  are  even  said  to  wholly  disappear,  though 
this  is  doubtful.  However,  they  are  sometimes  reduced  in  size  by  the 
end  of  "the  puerperium.  The  rule  is  that  they  are  not  markedly  reduced 
in  size  but  on  the  contrary  continue  to  grow  after  the  climacterium 
and  tend  to  degenerative  changes  and  extrusion. 

3.  The  Climacterium. — The  climacterium  is  generally  credited  with 
having  a  favorable  influence  upon  the  growth  of  uterine  fibroids,  but 
experience  points  to  the  reverse.  The  rule  is  that  they  continue  to 
grow  and  are  more  liable  to  degenerative  changes  at  this  time  of  life 
than  at  any  other.  Progressively  growing  postclimacteric  fibromyomata 
are  plentiful  in  the  literature.  Herman  reported  one  growing  thirteen 
years  after  the  menopause.  Tait  removed  one  twenty  years  after  the 
climacterium.  Van  Rensselaer  removed  a  submucous  myoma  from  a 
woman  ninety-two  years  of  age. 

Histogenesis. — According  to  Kleinwachter,  fibroids  originate  from 
round  cells  found  in  bloodvessels,  which  later  become  obliterated.  The 
round  cells  are  converted  into  muscle  and  connective-tissue  fibers. 

Rosger  believes  their  origin  to  be  in  the  muscle  fiber  of  bloodvessels. 
Gottschalk  is  of  the  opinion  that  it  is  not  the  musculature  of  the  blood- 


ANATOMICAL  DIAGNOSIS 


D// 


vessels  that  forms  the  matrix  of  the  tumor.  He  observed  amebic 
movements  in  certain  protoplasmic  bodies  which  he  interpreted  to 
be  parasites,  and  beheved  them  to  be  the  essential  cause  of  fibroids. 
Vedeler  thought  he  discovered  animal  parasites  in  uterine  fibroids. 
Virchow  believed  them  to  be  a  h\'perplasia  of  the  uterine  musculature. 
Judging  from  the  above  conflicting  opinions,  it  is  evident  that  nothing 
is  positively  known  of  the  histogenesis  of  uterine  fibroids. 

Fig.  378 


Cystic  fibromyoma  of  the  uterus  weighing  thirty-seven  pounds.     Successful  removal. 
(Dr.   J.    Clarence  Webster.) 


Anatomical  Diagnosis. — Under  this  head  we  will  consider  the  size, 
form,  consistency,  rate  of  gro"«i:h,  number,  and  position  of  the  tumor, 
and  also  its  microscopic  structure. 

In  size  uterine  fibroids  vary  from  almost  microscopic  dimensions 
to  the  tumor  reported  by  Hunter,  weighing  140  pounds  and  that  of 
Severann  weighing  195  pounds.  Webster  recently  reported  a  fibro- 
cystic tumor  of  the  uterus  weighing  87  pounds.  Recovery  followed 
37 


578 


FIBROMYOMA   OF   THE    UTERUS 


the  operation,  which  was  almost  wholly  performed  under  local  anes- 
thesia. So  far  as  I  am  able  to  find  in  the  records  this  is  the  largest 
uterine  fibroid  to  be  successfully  removed.  Adhesions  nearly  always 
complicate  these  large  tumors. 


Fig.  379 


Multiple  uterine  fibroids.  The  uterine  canal  is  distorted  by  two  large  interstitial  fibroids — a  pedun- 
culated and  a  senile  fibroid  occupies  the  surface  of  the  uterus,  and  on  the  opposite  (right)  side  is  a 
small  subperitoneal  fibroid.     (Specimen  removed  by  Dr.  J.  Clarence  Webster.) 


The  form  is  smooth  and  rounded,  or,  as  is  more  often  the  case, 
nodular. 

In  consistency  fibroids  vary  from  soft  and  semifluctuating  to  a  stone- 
like hardness.  Fibroids  are  classified  as  hard  and  soft.  Hard  fibroids 
consist  largely  of  fibrous  tissue,  with  a  relatively  smaU  amomit  of 
muscle  fiber;  the  blood  supply  is  not  great.  Soft  fibroids  are^made  up 
of  a  relatively  large  amount  of  muscle  tissue,  and  are  quite  vascular. 

The  rate  of  growth  of  soft  fibroids  is  more  rapid  than  that  of  hard 
fibroids.  During  pregnancy  fibroids  grow  rapidly.  After  the  meno- 
pause they  usually  decrease  in  size,  though  the  menopause  is  often 
delayed  three  to  ten  years.     They  are  seen  to  grow  with  surprising 


ANATOMICAL  DIAGNOSIS 


579 


rapidity  when  undergoing  myxomatous  degeneration.  Scholer  estimates 
that  fibroids  are  seldom  distinguishable  in  less  than  a  year;  that  in  five 
years  they  may  attain  to  the  size  of  a  man's  fist,  and 'in  thirteen  vears 
to  the  size  of  a  man's  head.  However,  it  is  not  possible  to  estimate 
the  age  of  a  tumor  by  its  size.  This  fact  is  demonstrated  by  the  many 
small  fibroids  which  are  known  to  be  thirty  and  forty  ^'ears  of  age— 
"latent  fibroids." 

Fig.  380 


Submucous  fibroid  of  the  uterus.     The  tumor  is  attached  to  the  posterior  wall  of  the  uterus  by 
a  broad  base.    The  overlying  mucous  membrane  is  atrophied. 

. ,  It  is  exceptional  for  fibroids  to  exist  singly.  As  many  as  400  separate 
and  distinct  tumors  have  existed  in  the  uterus.  We  speak  of  fibroids 
as  single  or  multiple. 


580 


FIBROMYOMA  OF  THE  UTERUS 


According  to  Martin,  the  tendency  to  multiplication  increases  with 
the  age  of  the  patient. 


Fig.  381 


Ain 


Bin 


cm 


Schematic  drawing  representing  the  development  of  uterine  fibroids  and  their  relation  to  the  uterine 
wall.  Al,  All,  AIII,  subperitoneal  fibroids.  BI,  BII,  BUI,  interstitial  fibroids.  CI,  CII,  CIII, 
submucous  fibroids,     (Suggested  by  Fehling.) 


The  position  of  fibroids  in  relation  to  the  uterine  wall  is  of  the  greatest 
clinical  importance.  The  terms  submucous,  intramural  or  interstitial, 
and  subserous  or  subperitoneal,  are  used  to  designate  the  location  of 


ANATOMICAL  DIAGNOSIS 


581 


the  tumor.  All  fibroids  are  originally  intramural,  and  as  they  increase 
in  size  they  tend  to  grow  in  the  direction  of  least  resistance.  For 
example,  an  intramural  fibroid  lying  nearer  the  endometrium  than  the 
perimetrium  will  eventually  become  submucous.  So  long  as  a  fibroid 
is  completely  enveloped  by  the  musculature,  no  matter  to  what  extent, 
it  is  intramural;  but  when  the  capsule  of  the  fibroid  is  immediately 
covered  with  peritoneum  or  mucosa  it  becomes  subperitoneal  or  sub- 
mucous. When  the  growth  is  attached  to  the  inner  or  outer  surface 
of  the  uterus,  with  a  broad  base,  it  is  known  as  a  sessile  growth;  when 

Fig.  382 


Submucous  fibroid  of  the  uterus.     The  uterus  is  evenly  distended  by  a  large  fibroid. 


the  base  of  attachment  is  constricted,  it  is  known  as  a  pedunculated 
growth.  The  more  pedunculated  the  tumor  the  slower  the  growth, 
because  of  the  limited  blood-supply  passing  through  the  pedicle.  The 
pedicle  when  long  may  so  limit  the  blood-supply  to  the  tumor  that 
atrophy  will  result.  Twisting  of  the  pedicle  may  completely  interrupt 
the  blood  supply,  in  which  case  the  fibroid  will  usually  become  gan- 
grenous. If  the  tumor  is  adherent  to  neighboring  structures,  a  requisite 
supply  may  be  conveyed  by  the  adhesions  and  prevent  necrosis.  A 
partial  twist  of  the  pedicle  may  be  followed  by  atrophy  or  edema  of 
the  tumor. 


582  FIBROMYOMA  OF  THE   UTERUS 

Spontaneous  amputation  of  the  tumor  by  lengthening  or  twisting 
of  the  pedicle  is  one  of  nature's  means  of  effecting  a  cure  in  submucous 
growths. 

Fibromyomata  of  the  cervix  occur  in  about  6  per  cent,  of  all  uterine 
fibromyomata. 

Fig.  383 


_  Pedunculated  submucous  fibroid  protruding  through  the  cervix.  The  fibroid  protrudes  from  the 
cervix  as  a  firm,  rounded  tumor  with  a  smooth  vascular  surface.  The  tumor  is  attached  by  a  pedicle 
to  the  body  of  the  uterus.  It  is  possible  for  such  a  growth  to  be  detached  and  spontaneously  expelled. 
(Specimen  removed  by  Dr.  J.  Clarence  Webster.) 

1.  Submucous  Fibromyomata. — Submucous  fibromyomata  bulge  into 
the  uterine  cavity  and  are  directly  covered  with  mucous  membrane. 
They  are  either  pedunculated  or  sessile,  single  or  multiple,  and  are 
seldom  as  large  as  the  patient's  head.    The  pedicle  may  permit  them 


ANATOMICAL  DIAGNOSIS  583 

to  protrude  into  the  ce^^'ical  canal  or  farther  on  into  the  vagina.  They 
usually  possess  a  relatively  large  amount  of  muscle  fiber  and  blood- 
vessels, and  hence  are  soft  in  consistency,  and  their  growth  is  rapid. 
When  large  and  soft  their  form  is  moulded  to  that  of  the  uterine  cavity. 
They  are  rarely  spherical,  but  more  often  elongated.  The  cervix  may 
constrict  them  into  an  hour-glass  shape.  As  the  tumor  increases  in 
size  the  overlying  mucosa  may  be  atrophied;  likewise,  the  opposing 
mucosa  of  the  uterus  may  suffer  pressure  atrophy,  and  adhesions  may 
form  between  the  tumor  and  uterine  mucosa.  This  explains  the  absence 
of  hemorrhage  in  many  of  the  large  submucous  fibroids.  Leyden  and 
Kiistner  described  a  case  in  which  a  fibromyoma,  having  become  detached 
from  the  uterus,  adhered  firmly  to  the  cervix.  Partial  inversion  of  the 
uterus  may  be  caused  by  traction  upon  the  fundus  by  a  pedunculated 
submucous  fibroid  attached  to  the  fundus.  The  effort  on  the  part  of 
the  uterus  to  expel  the  fibroid  causes  the  inversion. 

2.  Interstitial  Fibromyomata. — Interstitial  fibromyomata  lie  encap- 
sulated within  the  uterine  wall.  These  growths  are  rarely  distinguished 
from  the  uterine  musculature  (diffuse  fibromyomata).  When  large 
the  growth  bulges  upon  the  mucous  or  serous  surface  or  upon  both 
surfaces.  They  are  usually  multiple,  and  are  seldom  as  firm  in  con- 
sistency as  subserous  growths. 

3.  Subserous  Fibromyomata. — Subserous  fibromyomata  bulge  upon  the 
serous  surface  of  the  uterus.  They  are  single  or  multiple,  commonly 
firm  in  consistency,  though  sometimes  soft  and  apparently  fluctuating. 
When  pedunculated  they  ma}'  be  freely  movable  or  firmly  fixed  by 
adhesions  which  bind  the  growi:h  to  surrounding  structures.  When 
located  at  the  side  of  the  uterus  the  growth  may  develop  between  the 
layers  of  the  broad  ligament — intraligamentary  or  broad  ligament 
fibroids. 

Fibroids  of  the  Cervix. — Fibroids  of  the  cervix  may  be  submucous, 
interstitial,  or  subserous  (sub vaginal).  Submucous  fibroids  of  the 
cervix  are  seldom  large.  They  are  usually  pedunculated,  and  as  such 
are  known  as  fibrous  polyps. 

Interstitial  fibroids  of  the  cervix  distort  the  cervical  canal,  and  may 
cause  complete  obstruction,  locking  in  secretions  above,  and  preventing 
conception. 

Subserous  fibroids  of  the  cervix  are  very  rare,  and  seldom  of  large 
size.  They  may  grow  into  the  vagina  or  into  the  paravaginal  connective 
tissue.  About  10  per  cent,  of  uterine  fibroids  occur  in  the  cervix,  the 
balance  arising  from  the  uterine  body. 

Cervical  fibroids  are  poor  in  muscular  elements  and  hence  are  firm 
and  slow  in  growth.  They  are  prone  to  undergo  cystic  degeneration 
and  rarely  become  calcareous.  As  they  increase  in  size,  the  cervix 
becomes  elongated  and  distorted.  Amann  described  a  cervical  fibroid 
weighing  twenty-five  pounds.  Such  large  fibroids  elevate  the  uterus 
out  of  the  pelvis. 

On  cross-section  of  a  fibromyoma  bands  of  fibrous  and  muscular 
tissue  are  seen  to  run  in  various  directions  and  form  whorls,  concentric 


584 


FIBROMYOMA   OF  THE   UTERUS 


rings,  and  wa\  y  lines.  The  color  ^-a^ies  from  gray  to  a  rosy  hue,  depend- 
ing upon  the  relative  amounts  of  fibrous  and  muscular  tissue  and  upon 
the  blood-supply. 

Latent  Fibroids. — On  cross-section  uteri  are  frequently  seen  to  contain 
numerous  small  bodies  resembling  knots  of  wood.  Such  growths  are 
termed  "  latent  fibroids"  by  Bland  Sutton.  Their  whiteness  is  in  marked 
contrast  to  the  redness  of  the  musculature.  In  histological  structure 
they  are  identical  to  large  fibroids.  Undoubtedly  a  large  number  of 
fibroids  never  develop  beyond  this  stage.  Pregnancy  exercises  a 
quickening  influence  upon  these  latent  growths. 

Fig.  384 


Subperitoneal  fibroid  of  the  uterus.     The  uterus  is  crowded  backward  by  a  fibroid'attached 

to  the  anterior  wall. 


Recurrence  of  Uterine  Fibroids.— The  so-called  "recurrent  fibroids," 
referred  to  by  older  writers,  are  undoubtedly  accounted  for  by  the 
recurrence  of  what  was  an  unrecognized  malignant  growth,  and  secondly 
by  the  development  of  fibroids  which  were  overlooked.  jNIalignant 
groT\-ths  are  known  to  start  from  the  stump  of  an  amputated  fibroid. 
This  may  be  called  traumatic  malignancy,  and  is  not  peculiar  to  fibroids. 

Microscopic  Diagnosis. — The  microscopic  diagnosis  is  based  upon 
the  finding  of  mature  connective  tissue  and  muscle  fibers.  Without 
a  knowledge  of  the  gross  appearance  of  the  tumor  it  is  impossible  to 


ADENOFIBROMYOMA    UTERI 


585 


distinguish  a  fibroid  from  the  uterine  wah.  The  relative  amount  of 
connective  tissue  and  muscle  fibers  varies  widely. 

A  pure  fibroid  does  not  exist.  There  is  always  present  more  or  less 
muscular  tissue.  As  age  advances  the  connective  tissue  increases 
at  the  expense  of  the  muscular  elements.  The  muscle  fibers  are  invol- 
untary^  and  contain  spindle-formed  nuclei.  The  cell  protoplasm  is 
homogeneous  and  hardly  ever  granular.  On  cross-section  the  nucleus 
is  half-moon  shape.  Some  fibers  contain  two  or  more  nuclei.  Karyo- 
kinetic  figures  are  seldom  seen  in  the  muscle  cells  of  the  slow  developing 
growths,  but  are  present  in  proportion  to  the  rapidity  of  the  growth. 
The  connective  tissue  usually  forms  a  loose  texture,  poor  in  nuclei. 
In  associated  tumors  and  in  other  fields  of  the  same  tumor  the  con- 
nective tissue  may  be  more  compact  and  contain  round  or  oval  nuclei. 

Bloodvessels  course  through  the  connective  tissue.  Veins  are  not 
as  numerous  as  arteries,  particularly  in  old  fibromyomata.  A  central 
artery,  running  an  irregular  course  through  the  centre  of  the  fibroid,  is 
described  by  Gottschalk,  but  has  not  been  generally  recognized.  Lorey 
and  Hertz  have  described  nerve  fibers  in  fibromvomata. 


Fig.  3S5 


Adenomyoma  of  the  uterus.     (Hertzler.) 


Adenofibromyoma  Uteri. — Fibroids  containing  glands  are  described 
by  numerous  authorities.  Schroeder  believes  the  glands  originate  in 
■the  endometrium.  Carl  Ruge,  Gottschalk,  Kossman,  and  others 
maintain  that  they  arise  from  Gartner's  ducts.  Recklinghausen 
contends  that  the  glands  arise  from  the  Wolffian  body  or  from  the 
endometrium.  These  peculiar  growths  are  almost  invariably  intra- 
mural.    They  never  possess  a  capsule,  and  are  known  as  diffuse  or 


586  FIBROMYOMA  OF  THE   UTERUS 

infiltrating  fibroids.  They  are  found  in  the  tube,  the  uterine  horn, 
and  occasionally  in  the  posterior  wall  of  the  uterus. 

In  700  cases  of  uterine  fibroids  operated  in  Johns  Hopkins  Hospital, 
Cullen  reports  19  to  be  adenofibromata. 

Gebhard  gives  the  following  varieties: 

1.  A  hard  form  in  which  the  muscle  tissue  predominates  over  the 
glandular  elements. 

2.  A  cystic  tumor  with  many  large  spaces. 

3.  A  soft  form  in  which  the  glandular  elements  predominate  over 
the  fibrous  or  muscular. 

4.  A  soft  form  with  widened  blood  spaces — telangiectatic  or  angio- 
matous adenomyoma. 

In  the  growths  are  often  seen  small  ducts  communicating  with  a 
single  large  one  as  the  teeth  of  a  comb  are  joined  to  its  back.  These 
ducts  are  considered  by  many  to  be  embryonic  inclusions  of  the  ducts 
of  the  Wolffian  body  They  may  distend  into  cysts  and  compress  the 
surrounding  connective  tissue.  The  contents  of  the  cyst  are  clear 
and  serous,  occasionally  colored  by  pigment. 

Recklinghausen  speaks  of  pseudoglomeruli  in  describing  elevations 
attached  to  the  cyst  wall  by  a  broad  base. 

Pick  described  a  submucous  adenomyoma  which  weighed  55  grams. 
Cullen  reported  to  the  Johns  Hopkins  Society  an  adenomyoma  of  the 
round  ligament. 

Degeneration  of  Fibroids. — The  following  table  shows  the  relative 
frequency  of  the  various  degenerations  and  complications  in  the  tumor 
and  uterus  in  2274  cases  of  fibroid  tumors  collected  by  C.  P.  Noble: 

Carcinoma  of  the  corpus  uteri 42  or  1.8    per  cent. 

Carcinoma  of  the  cervix  uteri 16  or  0.7    per  cent. 

Sarcoma 34  or  1.4    per  cent. 

Chorio-epithelioma 2  or  0.1    per  cent. 

Necrosis  of  the  tumor 119  or  4.7    per  cent. 

Myxomatous  degeneration 89  or  3.4    per  cent. 

Cystic  degeneration 58  or  2.5    per  cent. 

Hyaline  degeneration 72  or  3.1    per  cent. 

Hyaline  degeneration  and  calcareous  infiltration      .  8  or  0.25  per  cent. 

Fatty  degeneration 7  or  0.03  per  cent. 

Hemorrhagic  degeneration 13  or  0.57  per  cent. 

Calcareous  infiltration 39  or  1.7    per  cent. 

Edema  of  tumor 17  or  0.74  per  cent. 

Twisted  pedicle 3  or  0.13  per  cent. 

Dangerous  hemorrhage 41  or  1.8    per  cent. 

Intrahgamentous  development  of  tumors       ...  80  or  3.5    per  cent. 

Subvesicle  development  of  tumor 2  or  0.01  per  cent. 

.Adenomyoma 12  or  0.06  per  cent. 

Total 664  or  26.49  per  cent. 

The  statistics  of  Noble,  Frederick,  Martin,  and  Cullingworth  prove 
that  fibroids  of  the  uterus  are  by  no  means  the  innocent  tumors  that 
former  writers  apparently  believed.  The  various  forms  of  degeneration 
of  fibroids  are  not  only  of  pathological  interest,  but  their  recognition  is 
of  the  greatest  clinical  importance. 


DEGENERATION  OF  FIBROIDS 


587 


Noble  estimates  that  serious  complications  arise  in  fibroids  in  about 
one-third  of  all  cases.  Of  these  complications  the  various  forms  of 
degeneration  constitute  a  large  proportion. 


Fig.  386 


Fibrous  polyp  of  the  cervix.  The  uterus  shows  senile  atrophy  together  with  three  small  subperitoneal 
fibroids.  The  polyp  is  of  unusual  size.  Such  polypoid  growths  are  prone  to  arise  in  a  senile  uterus. 
They  are  frequently  the  cause  of  hemorrhage  in  the  post-climacteric  period. 


1 .  Atrophy. — A  physiological  atrophy  of  fibroids  frequently  follows  the 
climacterium.  A  similar  change  takes  place  in  the  event  of  an  artifi- 
cially induced  menopause  by  the  removal  of  the  ovaries.  In  pedun- 
culated tumors  the  blood-supply  is  limited,  and  as  a  result,  atrophy 
may  follow.  The  wasting  diseases  exercise  a  staying  influence  upon 
the  growth  of  fibromyomata.  Atrophy  of  these  growths  has  been 
observed  to  follow  abdominal  sections,  amputation  of  the  breast,  and 
peritonitis.  According  to  Schroeder,  this  atrophy  consists  of  a  fatty 
degeneration.     It  is  more  probably  a  simple  atrophy,  in  which  the 


588 


FIBROMYOMA  OF  THE   UTERUS 


muscle  cells  diminish  in  size  and  in  number.  In  this  manner  large 
tumors  are  said  to  disappear. 

2.  Calcareous  Degeneration. — Calcareous  degeneration  may  occur  in 
fibroids  of  all  sizes  and  locations.  The  calcareous  deposits  are  found 
in  the  connective  tissue,  often  leaving  the  muscle  fibers  isolated  and 
encrusted . 

Gebhard  gives  the  following  analysis  of  the  deposit. 


Calc.  carb 

.     49.0 

Calc.  phosph 

29.0 

Calc.  sulph 

13.0 

Calc.  lithat 

0.5 

Organic  substances 

0.4 

Petrified  fibroids  are  known  as  "womb  stones."  It  is  possible  for 
such  stones  to  be  severed  from  the  uterus  and  lie  free  in  the  peritoneal 
cavity,  or,  if  submucous,  to  be  either  retained  in  the  uterus  or  expelled. 
Womb  stones  were  described  by  Hippocrates.  Everett  reported  one 
weighing  2.04  kg.  A  few  weighing  twenty  pounds  have  been  reported. 
Chondrification  and  ossification  have  also  been  reported.  Advanced 
age  predisposes  to  this  condition. 

Fig.  387 


Calcareous  myoma  of  the  uterus.     (Hertzler.)- 


3.  Fatty  Degeneration. — Fatty  degeneration  of  fibroids  is  of  common 
occurrence  following  pregnancy.  The  tumor  is  soft,  and  of  a  mottled 
yellow  tint.  Fat  droplets  are  seen  in  the  muscle  fibers.  Such  a  case 
was  exhibited  by  Dr.  Reuben  Peterson  before  the  Chicago  Gynecological 
Society. 


DEGENERATION  OF  FIBROIDS 


589 


4.  Myxomatous  Degeneration. — ^Myxomatous  degeneration  of  fibroids 
is  a  circumscribed  degeneration  of  the  connective  tissue.  There  is 
seldom  a  diffuse  involvement  of  the  tumor.  Before  cutting  into  the 
tumor  it  may  appear  cystic.  On  cross-section  one  or  more  areas  of 
degeneration  are  seen.  The  mj'xomatous  material  is  glairy  and  trans- 
lucent, containing  opaque  particles  and  a  fibrillar  or  fibrous  network. 
By  absorption  of  the  m^'xomatous  material  cystic  spaces  are  formed. 

Fig.  388 


A  pedunculated  subperitoneal  fibroid  lies  above  the  promontory  of  the  sacrum  and  is  too  large  to  fall 
into  the  pelvis.     It  has  drawn  the  uterus  and  vagina  upvrard. 


5.  Suppuration  and  Gangrene. — Suppuration  and  gangrene  of  fibroids 
is  a  grave  condition,  demanding  immediate  surgical  interference.  The 
usual  cause  is  puerperal  infection.  Subserous  fibroids  may  be  infected 
through  the  bowel.  Twisting  of  the  pedicle  of  a  fibroid  may  result  in 
gangrene. 

6.  Amyloid  Degeneration. — Amyloid  degeneration  of  a  fibroid  is 
described  by  Stratz. 

7.  Telangiectatic  Fibroids. — Telangiectatic  fibroids  are  of  rare  occur- 
rence. They  are  formed  either  from  a  dilatation  of  the  lymph  or  blood- 
spaces.    The  tumor  is  soft  and  may  fluctuate  and  even  pulsate. 


590 


FIBROMYOMA  OF  THE   UTERUS 


8.  Cystic  Degeneration. — Cysts  are  found  in  about  4  per  cent,  of 
all  uterine  fibroids.  The  subperitoneal,  and  particularly  the  pedun- 
culated forms,  are  especially  prone  to  undergo  cystic  degeneration. 
Sixty-three  out  of  seventy  cases  collected  by  Heer  were  subperi- 
toneal. These  cysts  are  usually  multiple.  They  are  prone  to  become 
infected,  in  which  case  the  cyst  may  be  converted  into  an  abscess. 
The  contents  may  be  discharged  into  the  peritoneal  cavity,  with  possible 
fatal  results.  All  of  the  largest  recorded  cases  of  uterine  fibroids  contain 
cysts.  In  the  fibrocystic  tumor  reported  and  operated  by  Webster, 
which  weighed  eighty-seven  pounds,  the  fluid  contents  of  the  cyst 

Fig.  389 


Honiorrhagic  myoma  of  the  uterus.      (Hertzler.) 


weighed  sixty  pounds.  Peritonitis,  hydroperitoneum,  intestinal  obstruc- 
tion, and  adhesions  frequently  complicate  these  cystic  growths.  We 
recognize  true  cysts  with  an  epithelial  lining  and  pseudocysts  which 
are  void  of  an  epithelial  lining  and  are  formed  by  the  degeneration  and 
absorption  of  tissue.  The  true  cysts  arise  from  epithelial  inclusions 
from  the  uterine  mucosa.  Wolffian  and  ]\Iullerian  tracts.  An  endothelial 
lining  has  been  demonstrated  by  several  authorities.  The  explanation 
for  the  origin  of  these  endothelial  cysts  lies  in  the  lymphatic  or  blood- 
canals.  The  contents  of  myomatous  cysts  are  clear  and  colorless,  bloody, 
purulent,  or  resemble  thick  pea  soup. 


CLINICAL   CHARACTERISTICS  591 

9.  Sarcomatous  Degeneration. — Sarcomatous  degeneration  of  fibroids 
will  be  discussed  in  the  Chapter  on  Sarcoma  of  the  Uterus. 

10.  Cancerous  Degeneration. — Cancerous  degeneration  is  an  unusual 
form.  The  epithelial  elements  are  derived  from  the  overlying  mucosa 
in  submucous  and  interstitial  growths  or  from  the  glandular  elements 
of  an  adenofibroma.  But  two  cases  are  recorded  in  which  the  cancer 
began  in  the  substance  of  the  fibroid. 

Changes  in  the  Endometrium,  Myometrium,  Tubes,  and  Ovaries. — 
The  endometrium  commonly  undergoes  hyperplastic  changes  under  the 
irritating  infliuence  of  the  fibroid.  Hence  it  is  that  these  changes  are 
almost  invariably  found  in  submucous,  usually  in  interstitial,  and  seldom 
in  subperitoneal  fibroids.  There  is  hypertrophy  and  hyperplasia  of  the 
elements  forming  the  endometrium.  In  large  fibroids  bulging  into  the 
uterine  cavity  there  may  be  pressure  atrophy  of  the  mucosa.  ^Yhen 
protruding  into- the  vagina  the  endometrium  may  be  transformed  into 
many  layers  of  stratified  epithelium,  and  decubitus  ulcers  may  form 
upon  the  surface. 

The  myometrium  becomes  hypertrophied.  This  is  particularly  true 
of  submucous  and  interstitial  growths.  The  hypertrophy  is  usually 
proportionate  to  the  size  and  number  of  the  tumors.  Champneys 
described  a  case  which  caused  such  atrophy  of  the  uterus  as  to  render 
the  musculature  scarcely  recognizable. 

The  tubes  and  ovaries  share  in  the  hypertrophy  of  tissues  to  a  limited 
extent.  It  is  estimated  that  the  tubes  are  diseased  in  10  per  cent,  of 
all  cases.  The  tubes  are  especially  liable  to  be  infected  in  the  presence 
of  infected  and  sloughing  fibroids. 

Clinical  Characteristics. — 1.  Shape. — A  fibroid  grows  concentrically, 
and  hence  is  usually  round.  The  firm,  subserous  tumors,  which  from 
their  location  are  less  influenced  by  the  uterus,  are  round  or  oval.  Sub- 
mucous fibroids  of  softer  consistency  are  moulded  by  the  uterus.  When 
forced  through  the  cervix  they  become  elongated  and  even  hour-glass- 
shaped.  Interstitial  fibroids,  confined  within  the  uterine  wall,  are 
round. 

2.  Mobility. — Only  pedunculated  submucous  and  subserous  fibroids 
move  independently  of  the  uterus.  Broad  ligament  fibroids  are 
restricted  in  their  movements.  Fixation  by  adhesions  and  by  incar- 
ceration restricts  the  movements  of  the  tumor  and  uterus. 

3.  Consistency. — The  consistency  of  a  fibroid  varies  from  a  stone- 
like hardness  to  the  softness  of  a  pregnant  uterus,  and  may  even  appear 
to  fluctuate.  This  variation  in  consistency  is  largely  to  be  accounted 
for  by  the  relative  proportions  of  flbrous  and  muscular  tissue  comprising 
the  growth.  The  more  fibrous  the  tissue,  the  harder  the  growth.  The 
forms  of  degeneration  causing  a  hardening  of  the  growth  are  atrophy 
(so-called  fibroid  degeneration),  calcareous,  cartilaginous,  and  osteo- 
matous  degenerations;  those  causing  a  softening  of  the  fibroid  are  fatty, 
myxomatous,  cystic,  edematous,  purulent,  gangrenous,  telangiectatic, 
sarcomatous,  and  cancerous  degenerations.  During  pregnancy  the  tumor 
softens  and  grows  rapidly;  after  pregnancy  it  becomes  smaller  and 


592  FIBROMYOMA  OF  THE  UTERUS 

firmer.  During  the  period  of  menstrual  congestion  the  growth  increases 
sHghtly  in  size  and  is  more  elastic. 

4.  Rate  of  Growth.^ — The  softer  and  more  vascular  the  tumor,  the 
more  rapid  its  growth.  It  is  important  to  observe  the  rate  of  growth 
in  distinguishing  a  growing  fibroid  from  a  pregnant  uterus  and  in 
determining  malignant  degeneration. 

Clinical  Diagnosis. — The  diagnosis  of  uterine  fibroids  rests  largely 
upon  the  local  findings.  Symptoms  at  best  are  only  suggestive  of 
their  possible  presence. 

Symptoms — Two  general  groups  of  symptoms  are  to  be  considered: 
those  due  to  hemorrhage,  and  those  due  to  pressure  and  traction  made 
by  the  growing  tumor. 

1.  Hemorrhage,  in  the  form  of  an  increase  of  the  menstrual  flow, 
is  usually  the  first  event  that  attracts  the  attention  of  the  patient. 
An  excessive  menstrual  flow,  beginning  late  in  the  childbearing  period 
and  associated  with  dysmenorrhea,  suggests  the  probable  presence  of 
uterine  fibroids.  As  time  goes  on  the  loss  of  blood  may  seriously 
undermine  the  patient's  health,  and  has  been  known  to  cause  death. 
There  may  be  no  intermission,  or  intervals  of  variable  length  may  be 
interrupted  by  profuse  and  even  alarming  hemorrhages.  It  is  seldom 
that  the  loss  of  blood  is  distinctly  and  exclusively  intermenstrual. 
The  blood  comes  from  the  endometrium,  rarely  from  the  fibroid.  The 
tumor  acts  as  a  foreign  body  irritating  the  endometrium.  Hence  it  is 
that  hemorrhage  occurs  almost  invariably  in  submucous  fibroids,  to 
a  lesser  extent  in  interstitial,  and  seldom  in  subperitoneal  fibroids. 
It  is  possible  for  a  subperitoneal  growth  to  interfere  with  the  circulation 
in  the  uterus  and  indirectly  cause  hemorrhage.  Mental  excitement, 
physical  exertion,  and  instrumental  and  digital  examinations  may 
excite  hemorrhage.  The  blood  is  often  expefled  in  clots.  This  clotting 
is  partly  the  result  of  obstruction  to  the  outflow  of  blood  by  the  tumor 
and  by  displacement  of  the  uterus. 

2.  Pressure  and  traction,  made  by  the  growing  tumor  upon  surrounding 
structures,  are  later  developments  than  hemorrhage,  and  are  not  usually 
manifest  until  the  tumor  has  attained  considerable  size.  Subperitoneal 
growths  are  most  likely  to  produce  these  symptoms.  A  variety  of 
symptoms  arises  from  direct  pressure  and  traction.  Pain  is  caused  by 
pressure  of  the  growing  uterus  and  tumor  upon  the  various  structures 
in  the  pelvis.  A  fibroid  tumor  incarcerated  in  the  small  pelvis  may  early 
cause  pain,  sometimes  to  an  intolerable  degree.  Intraligamentary  fibroids 
no  larger  than  a  man's  fist  may  occasion  distressing  pain.  On  the  other 
hand,  large,  freely  movable  fibroids,  occupying  the  abdominal  cavity, 
may  cause  no  pain.  The  pain  is  commonly  located  in  the  lumbar  and 
sacral  regions,  the  shoulders,  breasts,  and  thighs,  and  occasionally  in  the 
cervical  and  interscapular  regions. 

In  submucous  growths  the  pain  may  be  due  to  intermittent  uterine 
contractions,  excited  by  the  growing  fibroids.  Such  pains  are  usually 
colicky,  and  are  most  severe  during  the  period  of  menstrual  congestion. 
If,  as  sometimes  happens,  the  outflow  of  menstrual  blood  is  obstructed. 


CLINICAL  CHARACTERISTICS  593 

there  will  be  a  so-called  obstructive  dysmenorrhea,  due  to  intra-uterine 
tension  and  to  an  effort  on  the  part  of  the  uterus  to  expel  the  blood- 
clots.  Pain,  in  most  cases  of  uterine  fibroids,  first  manifests  itself  at 
the  menstrual  period,  when  the  uterus  and  tumor  are  swollen  and 
sensitive  from  congestion. 

The  "birth  of  a  fibroid" — i.  e.,  the  expulsion  of  a  submucous  fibroid 
— is  often  associated  with  labor-like  pains  of  astonishing  severity.  After 
the  flow  is  well  started  the  pain  may  be  relieved.  The  more  abundant 
the  blood-supply  to  the  tumor,  the  greater  will  be  the  menstrual  swelling. 
Acute  pain  on  external  pressure  may  be  experienced  in  the  menstrual 
period  from  irritation  of  the  peritoneum.  ^Mechanical  irritation  of 
the  peritoneum  caused  by  the  movable  tumor  may  set  up  a  localized 
peritonitis,  and  this  in  tiu-n  adds  to  the  pain  and  discomfort. 

Pressure  of  a  fibroid  upon  the  abdominal  and  thoracic  viscera  gives 
rise  to  a  variety  of  symptoms.  Pressure  upon  the  bladder  causes 
vesical  tenesmus,  frequent  urination,  and  catarrh  of  the  bladder.  A 
small,  subperitoneal  fibroid  attached  to  the  anterior  surface  of  the 
uterus  may  cause  serious  disturbance  in  the  bladder.  The  ureters  may 
be  compressed,  leading  to  hydronephrosis,  pyonephrosis,  and  uremia. 
The  urethra  is  rarely  pressed  upon  by  the  tumor,  though  the  bladder 
may  be  elevated  and  the  urethra  stretched  and  distorted. 

Pressure  upon  the  rectum  may  cause  constipation,  rectal  tenesmus, 
a  sense  of  fulness  and  pressure  in  the  rectum,  and  a  catarrhal  discharge 
from  the  bowel. 

Pressure  upon  the  veins  of  the  pelvis  may  cause  edema  and  vari- 
cosities of  the  lower  extremities. 

When  the  tumor  is  sufficiently  large  to  fill  the  abdominal  cavity, 
pressure  upon  the  bowel  and  stomach  will  interfere  with  digestion, 
and  pressure  upon  the  diaphragm  will  hinder  its  excursions,  and  thereby 
interfere  with  the  functions  of  the  heart  and  lungs.  Great  intra-abdomi- 
nal pressure  caused  b}'  large  fibroids  undoubtedly  embarrasses  the 
functions  of  the  kidneys. 

Torsion  of  the  pedicle  of  a  fibroid  is  possible;  furthermore,  it  is 
possible  for  a  fibroid  to  cause  torsion  of  the  uterus.  In  this  manner 
a  fibroid  may  be  completely  twisted  from  the  uterus.  Such  an  event 
must  necessarily  be  followed  by  gangrene  of  the  tumor,  unless  an 
adequate  blood-supply  is  con^'eyed  by  the  adhesions.  Immediately 
upon  the  twisting  of  the  pedicle  there  is  severe  abdominal  pain,  together 
with  a  sudden  increase  in  the  size  of  the  fibroid,  ^'omiting  and 
collapse  follow — the  clinical  picture  being  not  unlike  that  of  a 
strangulated  hernia,  or  the  twisted  pedicle  of  an  ovarian  cyst.  AMien 
the  torsion  is  partial  or  slow  in  its  development,  the  symptoms  will 
be  less  pronounced.  ^Yhen  a  fibroid  becomes  infected  or  gangrenous, 
the  event  will  be  ushered  in  by  a  rise  in  temperature,  chills,  and  pain. 
The  tumor  will  be  tender  to  pressure  and  increased  in  size.  When 
submucous,  a  stinking  discharge  will  come  from  the  uterus.  When  a 
subperitoneal  fibroid  becomes  gangrenous  the  symptoms  are  less 
characteristic.  Pain  may  be  absent.  Rise  of  temperature  and  tender- 
38 


594  FIBROMYOMA   OF   THE    UTERUS 

ness  on  pressure  are  all  but  constant  symptoms.  The  usual  signs  of 
peritonitis  supervene  when  the  infection  spreads  to  the  peritoneum. 

Calcareous  degeneration  gives  rise  to  no  symptoms  suggestive  of 
the  condition.  There  is  but  one  sign  upon  which  a  positive  diagnosis 
can  be  based,  and  that  is  the  expulsion  of  part  or  all  of  the  growth 
in  which  the  calcareous  deposits  are  found.  This  is  not  of  frequent 
occurrence  because  submucous  fibroids  rarely  calcify  and  under  such 
circumstances  are  seldom  expelled. 

Objective  Signs. — It  is  evident  that  a  positive  diagnosis  cannot  be 
made  from  the  above  subjective  signs.  From  them  we  can  only  conclude 
that  there  is  a  swelling  of  some  sort  causing  pressure  symptoms.  A 
physical  examination  is  indispensable  in  making  a  diagnosis. 

The  diagnosis  is  based  upon  the  recognition  of  a  tumor  connected, 
with  the  uterus  and  having  fairly  definite  'characteristics.  The  recog- 
nition of  a  fibroid  of  the  uterus  is  ordinarily  easy,  but  may  be  rendered 
difficult  by  various  circumstances.  In  order  that  a  diagnosis  of  fibroids 
may  be  made,  the  tumor  must  either  be  seen  or  outlined  by  the  examining 
hands.  Many  conditions  may  exist  to  render  such  a  procedure  impos- 
sible, and  at  such  times  the  diagnosis  must  be  reserved  until  an  exami- 
nation is  made  under  anesthesia  or  an  exploratory  incision  has  been 
made. 

Small  interstitial  fibroids  can  only  be  suspected  from  the  size  and 
irregular  consistency  of  the  uterus.  In  large,  interstitial  fibroids  there 
is  difficulty  in  outlining  the  uterus  apart  from  the  tumor.  The  sound 
passed  into  the  uterine  cavity  will  locate  the  uterus,  and  when  combined 
with  a  conjoined  examination,  it  should  be  possible  to  determine  the 
existence  of  a  fibroid  and  its  position  relative  to  the  uterus.  In  outlining 
the  respective  positions  of  the  uterus  and  tumor  it  is  important  to 
recognize  the  differences  in  their  form  and  consistency. 

A  subperitoneal  fibroid  is  ordinarily  identified  by  a  conjoined  exami- 
nation. \Mien  the  tumor  is  large,  abdominal  palpation  may  alone  be 
sufficient.  The  form,  consistency,  and  relation  to  the  uterus  may 
suffice  for  a  diagnosis.  Aluch  dependence  may  be  placed  upon  the 
firmer  consistency  of  the  tumor  as  compared  with  the  uterus,  and 
particularly  is  this  of  importance  in  difi'erentiating  a  fibroid  from  a 
pregnant  uterus. 

As  with  interstitial  fibroids,  great  difficulty  may  be  experienced  in 
outlining  a  large,  sessile,  subperitoneal  fibroid  from  the  uterus.  The 
irregular  outline,  the  firmer  consistency,  the  groove  or  angle  which 
may  mark  the  connection  between  tumor  and  uterus,  are  points  which, 
together  with  the  use  of  the  soimd,  should  suffice  for  a  diagnosis  in  the 
majority  of  cases.  Greater  difficulty  is  experienced  with  multiple 
subperitoneal  fibroids. 

In  large  fibroids  a  vascular  souffie  is  often  heard  and  may  be  mistaken 
for  the  souffle  of  pregnancy.  The  pulsations  of  the  aorta  may  be 
transmitted  through  the  tumor  and  be  mistaken  for  the  fetal  heart- 
beat. 

Intraligamentary  or  broad  ligament  fibroids  are  recognized  by  their 


CLINIC  A  L  CHA  RA  CTERIS  TICS 


595 


point  of  attachment  along  the  side  of  the  uterus,  by  their  lessened 
mobility,  by  the  course  of  the  adnexae  which  run  over  the  tumor,  and 
by  the  crowding  of  the  uterus  to  the  opposite  side  of  the  pelvis.  The 
growth  may  spring  from  the  supravaginal  portion  of  the  cervix  or  from 
the  side  of  the  uterine  body. 

Plate  IV  represents  a  single,  large,  subperitoneal  fibroid  causing  a 
rounded  protuberance  of  the  abdomen.  Plate  V  represents  an  abdomen 
distended  by  multiple  subperitoneal  fibroids,  in  which  the  irregularities 
are  plainly  visible. 

Fig.  390 


Area  of  dulness  in  multiple  fibroid  of  the  uterus. 

Submucous  fibroids  can  only  be  diagnosticated  with  certainty  when 
they  are  seen  protruding  through  the  cervix  or  when  palpated  through 
the  cervical  canal.  The  hemorrhage  and  uterine  colic  will  suggest  the 
possible  presence  of  a  submucous  fibroid,  but  the  diagnosis  must  be 
kept  in  reserve  for  a  physical  examination.  Within  the  uterine  cavity 
the  finger  detects  a  firm,  rounded  tumor  connected  with  the  uterus 
by  a  broad  base  or  pedicle.  The  fibroid  may  be  felt  as  a  circumscribed 
tumor  bulging  upon  the  mucosa.  With  the  sound  or  curet  similar 
observations  may  be  made,  though  with  less  certainty. 

Fibroids  of  the  cervix  are  not  difficult  to  diagnosticate  when  attached 
to  the  vaginal  portion.  Their  attachment  to  the  cervix  can  be  demon- 
strated by  inspection  or  by  the  finger  and  sound.  Small  interstitial 
fibroids  of  the  cervix  are  recognized  by  the  firm,  rounded,  and  sharply 
circumscribed  area  of  resistance  which  characterizes  their  presence. 

The  use  of  the  sound  in  the  diagnosis  of  uterine  fibroids  is  not  to 


596 


FIBRO MYOMA   OF  THE  UTERUS 


be  underestimated,  yet  its  application  should  be  restricted  to  the 
cases  in  which  a  conjoined  examination  fails  to  clear  up  the  diagnosis. 
Aside  from  the  danger  of  infection  there  is  the  added  risk  of  perfor- 


FiG.  392 


Fig.   393 


Fig.  394 


It  is  sometimes  possible  to  locate  a  fibroid  in  relation  to  the  uterus  by  palpating  the  uterine  appendages 

and  round  ligaments. 
Fig.  391.  The  fibroid  is  subperitoneal  and  sits  upon  the  fundus,  hence  the  appendages  and  round 
ligaments  are  not  disturbed  in  their  relative  positions.  Fig.  392.  The  fibroid  is  subperitoneal  and 
-sits  upon  the  posterior  wall  of  the  uterus,  and  extends  backward  and  to  the  left.  The  appendages 
and  round  ligaments  are  not  disturbed  in  their  relative  positions.  Fig.  393.  The  fibroid  is  interstitial 
and  evenly  distends  the  uterus,  hence  the  appendages  and  round  ligaments  are  separated  on  the  same 
plane.  Fig.  394.  The  fibroid  is  interstitial  and  lies  in  the  fundus  and  right  cornua.  The  right  tube 
and  round  ligament  are  elevated  and  dislocated  outward.  ' 

ating  the  uterus  at  a  point  thinned  by  the  tumor.  Great  difficulty 
may  be  experienced  in  the  passage  of  the  sound.  The  tumor  may  be 
impinged  upon  and  give  the  impression  that  the  depth  of  the  uterus  is 
short  in  contrast  to  the  usual  lengthening  of  the  uterine  cavity,  as  found 


DIFFERENTIAL  DIAGNOSIS  597 

in  the  presence  of  submucous  and  interstitial  fibroids.  The  shape 
of  the  uterine  cavity  is  also  to  be  noted  by  the  sound.  It  may  be 
encroached  upon  and  greatly  distorted,  so  much  so  that  the  uterine 
sound  cannot  be  passed  to  the  fundus. 

Palpation  of  the  Adnexae  and  Round  Ligaments. — In  favorable  cases 
the  tubes  and  round  ligaments  can  be  palpated  by  a  conjoined  examina- 
tion. It  is  observed  that  their  location  and  points  of  attachment  are 
altered  by  the  tumor,  and  it  is  sometimes  possible  to  locate  the  tumor 
in  its  relation  to  the  uterus  by  observing  the  position  of  the  adnexse 
and  round  ligaments. 

When  the  uterus  is  small  and  a  large  fibroid  rests  upon  the  fundus, 
the  tumor  may  be  mistaken  for  the  uterus.  The  attachment  of  the 
tubes  and  round  ligaments,  when  determined,  will  indicate  the  position 
of  the  uterus  apart  from  the  tumor.    The  sound  will  confirm  the  findings. 

A  submucous  or  interstitial  growth,  evenly  distending  the  uterus,  will 
separate  the  attachments  of  the  round  ligaments  and  adnexse.  An 
interstitial  fibroid  of  the  anterior  wall  will  separate  the  round  ligaments 
and  tubes,  and  if  it  be  to  one  side  of  the  median  line,  the  correspond- 
ing tube  and  round  ligament  will  be  elevated  above  the  other.  An 
interstitial  fibroid  on  the  posterior  surface  of  the  uterus  will  tend  to 
approximate  the  appendages.  If  the  fibroid  is  on  the  side  of  the  uterus 
the  corresponding  round  ligaments  and  tube  may  be  elevated.  Figs.  397 
to  400  illustrate  these  facts.  The  diagnosis  of  malignant  degeneration 
of  a-  fibroid  is  discussed  in  the  chapter  on  Sarcoma  of  the  Uterus. 

Differential  Diagnosis. — Fibroids  of  the  uterus  commonly  appear 
during  the  period  of  sexual  maturity  when  pregnancy,  inflammatory 
lesions,  and  displacements  are  liable  to  arise,  and  it  is  for  this  reason 
that  the  differential  diagnosis  is  of  such  importance. 

Interstitial  Fibroids  Chronic  Metritis 

1.  Irregular    enlargement    of    the    uterus    unless       1.   Uniform  enlargement. 

tumors  are  small. 

2.  Variable  consistency.  2.   Uniform,  firm  consistency. 

3.  Not  tender  to  pressure.  3.  Commonly  tender  to  pressure. 

4.  Uterus  freely  movable.  4.  Uterus  usually   restricted   in  its   movements. 

5.  No  history  of  infection.  '  5.  History  of  infection. 

6.  Symptoms  of  uterine  catarrh  not  common.  6.   Symptoms  of  uterine  catarrh  generally  present. 

When  the  fibroids  are  multiple  and  small  it  may  be  impossible  to 
distinguish  such  a  lesion  from  chronic  metritis.  The  clinical  history 
cannot  be  relied  upon. 

Uterine  Fibroids  Uterine  Pregnancy 

1.  Usual  signs  of  pregnancy  absent.  1.  Present. 

2.  Tumor  of  firm  consistency,  rarely  soft.  2.  Soft  and  elastic. 

3.  Intermittent  uterine  contractions  absent.  3.  Present. 

4.  Irregular  and  asymmetrical  growth.  4.  Rate  of  growth  regular  and  symmetrical. 

5.  Slow  growth.  5.  More  rapid  growth. 

6.  Cervix  firm,  not  patulous.  6.  Cervix  soft  and  patulous. 

7.  Positive  signs  of  pregnancy  absent.  7.  One  or  more  present,  i.  e.: 

a.  Fetal  heart  tones. 

b.  Placental  bruit. 

c.  Active  fetal  movements. 

d.  Palpation  of  fetal  parts. 
--                                                                                 e.  Ballottement. 


598 


FIBROMYOMA   OF   THE   UTERUS 


Of  greatest  importance  in  the  differential  diagnosis  of  fibroids  from 
early  pregnancy  is  the  uniform,  rapid  growth  of  the  pregnant  uterus, 
the  intermittent  uterine  contractions  and  characteristic  doughy  con- 
sistency of  the  uterus.  Later,  when  positive  signs  of  pregnancy  are 
elicited,  there  should  be  no  mistaking  the  fact  of  pregnancy. 


Fig.  395 


Subperitoneal  fibroid  of  the  uterus  in  the  third  month  of  pregnancy.  On  the  posterior  surface  of 
the  body  of  the  uterus  and  cervix  is  a  hard  subperitoneal  fibroid,  the  size  of  a  fetal  head.  The  uterine 
wall  is  abnormally  thickened.  The  ovary  is  cystic  and  adherent  to  the  tube  and  uterus.  (Specimen 
was  removed  by  Dr.  J.  Clarence  Webster.) 

A  large,  soft,  interstitial  fibroid  may  evenly  distend  the  uterus. 
Its  soft  consistency,  regular  outline,  and  rapid  growth  may  suggest 
the  presence  of  a  pregnant  uterus.  In  addition  to  the  above  findings 
there  may  be  nausea  and  vomiting,  enlargement  of  the  breasts,  and  soft- 
ening and  discoloration  of  the  vaginal  portion  of  the  cervix.  With  such 
a  condition  it  may  be  impossible  to  differentiate  from  early  pregnancy. 
Keeping  the  case  under  observation  for  a  few  weeks,  it  will  be  noted 


Pregnant  Myomatous  Uterus.      Medial  Section  of  Pelvis. 

(Leipmann.) 


J.  Foot  of  fetus. 

2.  Umbilical  cord. 

3.  Fibroid  in  posterior  wall  of  uterus. 

4.  Head  of  fetus. 

5.  Rectum. 

6.  Recto-uterine  fold. 

7.  External  os. 

8.  Anus. 


9.  Vesico-uterine  fold. 

10.  Vagina. 

11.  Urinary  bladder. 

12.  Urethra. 

13.  Peritoneum. 

14.  Os  pubis. 

15.  Fibroid  in  anterior  wall  of  uterus. 

16.  Necrotic  area  in  fibroid. 


DIFFERENTIAL  DIAGNOSIS 


599 


that  the  growth  is  slower  than  in  pregnancy,  that  there  are  no  inter- 
mittent contractions,  and  that  none  of  the  positive  signs  of  pregnancy 
develops. 


Fig.  396 


Multiple  interstitial  fibroids  in  a  full-term  pregnant  uterus.  The  placenta  is  retained  in  situ.  The 
irregular  contractions  of  the  uterus,  due  to  the  presence  of  the  fibroid  tumors,  are  shown  by  the  irregular 
course  of  the  uterine  cavity.  (The  uterus  was  removed  by  Dr.  J.  Clarence  Webster  immediately  follow- 
ing a  Cesarean  section.) 

The  diagnosis  of  fibroids  complicated  by  pregnancy  is  often  a  diffi- 
cult problem.  Small,  subperitoneal  fibroids  may  be  mistaken  for  part 
of  the  fetus.  Under  the  influence  of  pregnancy  a  fibroid  usually  grows 
rapidly  and  becomes  soft.  It  is,  however,  unusual  for  the  growth  to 
become  as  soft  as  the  pregnant  uterus,  so  by  the  circumscribed  area 
of  firmer  resistance,  the  fibroid  is  outlined  apart  from  the  pregnant 
uterus.  If  the  examination  is  made  during  a  uterine  contraction,  this 
difference  in  consistency  between  the  uterus  and  fibroid  is  not  evident. 
Repeated  and  prolonged  examinations  may  be  required. 

No  tumor  other  than  a  pregnant  uterus  displays  these  intermittent 
contractions. 


600  FIBROMYOMA  OF  THE   UTERUS 

When,  through  a  morbid  state  of  the  contained  fetus,  the  uterus 
remains  in  a  condition  of  tonic  contraction,  the  discovery  of  an  inter- 
stitial fibroid  may  be  impossible.  When  in  doubt  as  to  the  diagnosis, 
and  the  condition  of  the  patient  does  not  demand  immediate  inter- 
ference, it  is  always  advisable  to  await  developments  and  make 
examinations  at  frequent  intervals. 

Subserous  Uterine  Fibroids  Hematoma  and  Hematocele 

1.  No  history  of  recent  pregnancy.  1.  Frequently  history  of  previous  pregnancy. 

2.  Slow,  continued  development.  2.  Sudden  development. 

3.  Consistency  firm,  rarely  soft.  3.  Consistency    at    first    is    fluctuating,    later   is 

doughy. 

4.  Sharply  circumscribed  tumor.  4.  Ill-defined  tumor. 

5.  Exploratory  puncture  negative.  5.  Exploratory  puncture — blood  obtained. 

Gangrene  with  fatal  termination  has  been  known  to  follow  an 
exploratory  puncture  of  a  fibroid.  It  is  not  always  possible  to  remove 
blood  through  an  exploratory  needle  because  of  the  firm  clotting.  In 
this  event  an  exploratory  incision  must  be  substituted. 

For  the  dififerential  diagnosis  of  uterine  fibroids  from  displacements 
of  the  uterus,  carcinoma,  sarcoma,  tubal  and  ovarian  swellings,  and 
pelvic  exudates,  see  respective  chapters  on  these  subjects. 

A  case  in  the  experience  of  the  author,  and  another  observed  by 
Bayard  Holmes,  presented  a  soft  subperitoneal  fibroid  near  the  horn 
of  a  pregnant  uterus  which  was  thought  to  be  an  ectopic  gestation.. 
In  both  cases  the  pregnancy  was  early;  the  fibroids  were  not  discovered 
until  the  pregnant  uterus  began  to  rise  out  of  the  pelvis,  bringing  the 
softened  tumor  with  it. 

Fibroids  Imperil  Life. — Fibroids  may  exist  without  the  know^ledge  of 
the  individual  carrying  them.  Again,  they  may  be  the  source  of  much 
distress,  and  may  be  the  direct  or  indirect  cause  of  death.  The  follow- 
ing are  the  incidents  which  seriously  influence  a  myomatous  patient: 

1.  Hemorrhage. — Hemorrhage  is  the  most  common,  though  not  the 
most  serious,  event.  Little  need  be  added  to  what  has  already  been  said. 
While  the  patient's  health  may  be  seriously  influenced  by  loss  of  blood, 
it  must  be  remembered  that  this  is  not  alone  the  result  of  a  loss  of 
large  quantities  of  blood.  What  may  appear  to  be  an  insignificant 
amount,  when  continued  over  many  months  and  years,  may  produce 
a  chronic  anemia,  not  unlike  pernicious  anemia  in  its  clinical  features. 
Excessive  bleeding  from  a  fibroid  during  and  between  menstrual  periods 
usually  indicates  septic  infection  of  the  tumor. 

2.  Complicating  Pregnancy. — The  gravity  of  fibroids  complicating 
pregnancy  depends  in  great  part  upon  the  size  and  position  of  the 
tumor.  Submucous  fibroids  have  the  most  serious  influence  and 
subperitoneal  the  least. 

A  submucous  fibroid  predisposes  to  abortion,  interferes  with  the 
complete  emptying  of  the  uterus,  and  hence  renders  the  patient  liable 
to  infection  and  hemorrhage.  Septic  infection  and  sloughing  of  these 
growths  may  follow.     Subperitoneal  fibroids  may  become  edematous 


DIFFERENTIAL  DIAGNOSIS  601 

or  infected  and  lead  to  peritonitis.  Twisting  of  the  pedicle  of  a  sub- 
peritoneal fibroid  is  an  occasional  accident  which  leads  to  severe  pain, 
gangrene  of  the  tumor,  and  peritonitis.  In  the  Baudelocque,  1895  to 
1900,  there  were  85  cases  of  uterine  fibroids  complicated  by  pregnancy. 
Meneut  reports  67  of  these  having  gone  to  full  term  and  13  aborted; 
in  2  cases  abortion  was  induced,  and  death  occurred  in  2  cases. 

Tait  found  in  the  literature  39  cases  of  polypoid  myomata  complicat- 
ing pregnancy.  Of  this  number  gangrene  of  the  tumor  occurred  in  6, 
spontaneous  expulsion  of  the  fetus  together  with  much  loss  of  blood 
in  3,  myomectomy  in  7,  normal  delivery  in  10,  maternal  deaths  in  8. 

3.  Septic  Infection. — Septic  infection  is  a  most  serious  complication 
and  demands  immediate  and  radical  treatment. 

The  infection  may  be  conveyed  to  the  fibroid  by  instruments  and 
fingers.  More  often  it  arises  through  an  infected  puerperal  wound  of 
the  uterus.  Tumors  adhering  to  the  bowel  may  be  infected  from  the 
bowel.  A  submucous  fibroid,  protruding  through  the  cervix  into  the 
vagina,  may  be  so  constricted  as  to  partly  shut  off  the  blood  supply 
and  lead  to  edema  and  congestion,  which  may  later  result  in  gangrene 
of  the  fibroid  with  all  its  remote  consequences. 

4.  Torsion  of  the  Pedicle. — A  long,  slender  pedicle  of  a  subperitoneal 
fibroid  may  permit  of  rotation  of  the  fibroid  in  exactly  the  same  manner 
as  in  ovarian  cysts.  The  accident  is  a  rare  one.  Conditions  which 
favor  rotation  of  the  fibroid  are  a  long,  slender  pedicle,  free  fluid  in 
the  abdomen,  sudden  increase  in  the  intra-abdominal  pressure,  preg- 
nancy, the  sudden  emptying  of  the  pregnant  uterus,  and  lastly,  direct 
injury.  The  consequences  of  such  twisting  are  gangrene  of  the  fibroid, 
followed  by  peritonitis  unless  surgical  interference  is  timely.  Calcar- 
eous fibroids  have  twisted  off  and  have  been  found  free  in  the  abdominal 
cavity,  but  giving  rise  to  no  disturbances. 

5.  Impaction. — Impaction  in  the  small  pelvis  may  occur  from  all 
varieties  of  fibroids,  but  it  is  far  more  common  in  subperitoneal 
fibroids.  This  event  is  especially  liable  in  pregnancy,  at  which  time  the 
tumor  and  uterus  grow  rapidly.  Retention  of  urine  may  be  caused 
by  direct  pressure  upon  the  urethra.  Frequent  urination  results  from 
pressure  upon  the  bladder.  When  long  continued  the  bladder  and 
kidneys  may  suffer  permanent  injury.  Bland  Sutton  lays  down  the 
rule  that  "when  a  woman  between  thirty-five  and  forty-five  seeks 
relief  because  she  sufi^ers  from  retention  of  urine  for  a  few  days  preceding 
each  menstrual  flow  it  is  almost  certain  that  she  has  a  fibroid  in  the 
uterus."  Broad  ligament  fibroids  are  especially  liable  to  impaction, 
and  the  pressure  exerted  by  them  upon  the  ureter,  pelvic  nerves,  and 
bloodvessels  may  early  become  serious. 

6.  Intestinal  Obstruction. — Intestinal  obstruction  may  arise  from 
direct  pressure  of  the  growth  or  from  the  entanglement  of  the  intestinal 
loops  with  the  pedicle  of  a  subperitoneal  fibroid. 

7.  Nutritive  Changes. — Nutritive  changes  in  the  fibroid  may  imperil 
life.  Fibroids  grow  almost  invariably  during  the  period  of  gestation, 
and  particularly  in  the  early  months.    The  increase  in  the  size  of  the 


602  FIBROMYOMA  OF  THE   UTERUS 

tumor  may  be  so  rapid  and  attain  such  a  large  size  as  to  seriously 
embarrass  not  only  the  course  of  pregnancy  and  labor,  but  also  the 
functions  of  the  abdominal  viscera. 

During  labor,  degenerative  changes  may  occur  in  the  fibroid  as  the 
direct  result  of  trauma.  Such  tumors  are  usually  located  low  in  the 
pelvis.  According  to  Hammarschlag  these  changes  are  not  necessarily 
dependent  upon  trauma,  but  may  arise  independent  of  injury.  It 
must  be  admitted  that  fibroid  tumors  of  the  uterus,  even  of  large 
proportions,  seldom  impede  the  progress  of  labor.  Statistics  from  the 
large  clinics  of  the  world  justify  this  assertion. 

During  the  lying-in  period  the  usual  tendency  of  fibroids  is  to  undergo 
involution,  even  to  the  point  of  apparently  disappearing.  Hammarschlag 
finds  that  the  sudden  cessation  of  the  free  blood  supply  which  exists 
during  pregnancy  sometimes  brings  about  marked  necrotic  changes 
in  the  tumor  which  may  seriously  affect  the  patient. 

Edema  of  the  tumor  may  occur  during  pregnancy,  labor,  and  in 
the  lying-in  period.  During  pregnancy  such  an  event  must  be  looked 
upon  as  a  fortunate  happening,  inasmuch  as  the  softening  of  the  tumor 
permits  of  such  moulding  of  the  growth  by  the  pressure  of  the  advancing 
child  that  delivery  will  be  favored. 

Hemorrhage  from  the  severing  of  adhesions  may  arise  during  the 
latter  part  of  pregnancy  and  in  labor.  Fatal  results  have  been  recorded. 
This  event  is  especially  liable  to  occur  when  artificial  reposition  is 
attempted.  Hemorrhage  and  peritonitis  have  been  known  to  result 
from  the  twisting  of  the  pedicle  of  a  subperitoneal  fibroid.  Expulsion 
of  a  submucous  fibroid  during  labor  and  the  puerperium  is  a  not  infre- 
quent event,  and  may  be  followed  by  serious  infection. 

8.  Cardiopathy  of  Uterine  Fibroids. — Cardiopathy  of  uterine  fibroids 
is  a  condition  demanding  serious  consideration  because  of  the  gravity 
of  the  condition  and  its  frequent  occurrence,  ^'a^ious  functional  and 
organic  lesions  of  the  heart  are  found  to  be  associated  with  uterine 
fibroids  in  about  40  per  cent,  of  cases,  not  simply  as  a  coincidence  but 
as  an  inevitable  result  in  some  cases.  It  is  therefore  imperative  to 
look  to  the  heart  in  all  cases. 

McGlinn  draws  the  following  conclusions  from  his  study  of  a  large 
number  of  autopsies: 

First.     A  definite  entity  of  a  fibroid  heart  cannot  be  sustained. 

Second.  If  the  fibroid  tumors  of  the  uterus  were  the  cause  of  all 
heart  lesions  then  every  tumor,  regardless  of  its  size  and  situation, 
should  be  removed.  A  contention  that  the  most  radical  would  hardly 
admit. 

Third.  Uterine  myomata,  occurring  in  middle  and  advanced  life, 
are  practically  always  associated  with  sclerotic  heart  lesions.^  These 
lesions  are  a  part  of  a  general  process  and  bear  no  relation  to  the 
fibroid. 

Fourth.  Large  tumors,  by  increasing  the  work  of  the  heart,  and 
tumors  causing  pressure  on  the  pelvic  circulation  may  produce  hyper- 
trophy and  secondary  dilatation  of  the  heart. 


DIFFERENTIAL  DIAGNOSIS 


603 


_  Fifth.     Anemia  from  hemorrhages,  infections,  and  certain  degenera- 
tions of  the  tumor  may  affect  the  heart,  secondarily  causing  changes 
such  as  fatty  degeneration,  brown  atrophy,  and  cloudv  swelHng 


Fig.   397 


Multiple  fibroids  of  the  uterus,  with  sarcomatous  degeneration. 
Fig.  398 


'It 


^ 


^if>'^. 


.&i 


^' 


£^t.^   _<^. 


/ 


^"^^-^^^     -^K^-^    ^y 


/^l 


Spindle-cell  sarcoma.     Section  taken  from  centre  of  a  large  fibroid  in  Fig.  395. 

Sixth.  The  majority  of  cases  of  fatty  degeneration,  brown  atroph\-. 
cloudy  swelling,  myocarditis,  etc.,  found  in  connection  with  fibroid 
tumors  of  the  uterus,  are  not  caused  by  the  tumor  but  b^•  conditions 
entirely  foreign  to  the  tumor. 


604       .  FIBROMYOMA  OF  THE   UTERUS 

9.  Malignant  Degeneration. — Malignant  degeneration  of  uterine 
fibroids  occurs  in  3  to  4  per  cent,  of  all  cases,  according  to  Winter. 
These  changes  are  almost  invariably  sarcomatous. 

Coincident  malignant  disease  of  the  uterus  with  fibroids  has  been 
frequently  observed,  but  to  establish  a  relationship  of  cause  and 
effect  is  not  justifiable.  The  fact  that  they  occasionally  occupy  the 
same  uterus  should  lead  to  the  consideration  of  the  possible  existence 
of  the  two  lesions  in  all  cases. 

Causes  of  Death  from  Uterine  Fibroids. — Pellanda  tabulates  the  causes 
of  death  in  171  cases  of  uterine  fibroids  as  follows: 

1.  Cachexia,  9  cases,  or  5.2  per  cent. 

2.  Hemorrhage,  11  cases,  or  6.4  per  cent. 

3.  Infection,  85  cases,  or  49.5  per  cent.  The  majority  were  dependent 
on  labor  and  abortion  followed  by  infection. 

4.  Compression  of  abdominal  and  pelvic  viscera,  44  cases,  or  25.8 
per   cent. 

5.  Thrombosis  of  the  pelvic  veins  followed  by  pulmonary  embolism; 
also  cardiac  lesions  and  sudden  syncope,  19  cases,  or  11.1  per  cent. 

6.  Torsion  of  pedunculated  subserous  fibroid,  3  cases. 

More  patients  die  from  postoperative  complications  than  from  the 
tumor   itself. 

Effect  of  Fibroid  Tumors  upon  Neighboring  Organs. — By  compression 
of  neighboring  organs,  fibroid  tumors  create  circulatory  disturbances  in 
these  organs  and  so  compress  and  distort  them  as  to  give  rise  to  serious 
functional  disturbances.  The  bladder,  rectum,  ureters,  and  urethra  suffer 
greatest  from  compression.  The  bladder  may  be  elevated  to  the  level 
of  the  umbilicus.  The  urethra  may  be  greatly  elongated,  and  com- 
pression of  the  urethra  may  lead  to  retention  of  urine  within  the  bladder. 
Hydro-ureter  and  hydronephrosis,  with  possible  destruction  of  the 
parenchyma  of  the  kidney,  may  result  from  compression  of  the  ureters. 
Intraligamentary  fibroids  are  prone  to  distort  and  displace  the  ureter. 
Compression  of  the  rectum  may  give  rise  to  constipation,  distention 
of  the  bowel  above  the  point  of  compression,  and  to  hemorrhoids. 
Complete  obstruction  probably  never  occurs. 

Effect  of  Fibroid  Tumors  upon  the  Blood. — Noble  reported  a  case 
with  10  per  cent,  of  hemoglobin  and  another  with  15  per  cent.  The 
anemia  may  be  so  profound,  as  the  result  of  the  hemorrhages,  as  to 
produce  permanent  invalidism,  and  is  known  to  result  fatally.  Telanda, 
in  a  report  of  171  cases  of  death  from  fibroids  without  operation,  records 
a  mortality  of  6.4  per  cent,  as  the  result  of  hemorrhage.  The  cardiac 
weaknesses  and  kidney  insufficiencies,  as  the  result  of  anemia,  will 
explain  a  certain  number  of  deaths  in  operated  and  non-operated 
cases. 

Thrombosis,  Embolism,  and  Phlebitis. — Fibroid  tumors  of  the  uterus 
cause  thrombosis,  embolism,  and  phlebitis  more  often  than  any  other 
pelvic  lesion,  the  pelvic  veins  and  veins  of  the  legs  being  most  often 
involved.  Embolism  of  the  lungs  following  thrombosis  of  these  veins  is 
one  source  of  sudden  death  following  operation  for  removal  of  a  fibroid. 


TREATMENT  OF   UTERINE  FIBROIDS  605 

The  contributing  factors  leading  to  thrombosis,  phlebitis,  and  embol- 
ism are  anemia,  slowing  of  the  circulation,  injury  to  the  veins,  and 
infection. 

Treatment  of  Uterine  Fibroids. — The  improved  technic  of  myo- 
mectomy and  of  hysterectomy,  together  with  a  better  understanding 
of  the  dangers  of  fibroids,  has  resulted  in  a  revolution  of  the  treatment 
of  fibroid  tumors  of  the  uterus.  Expectant  treatment  is  no  longer 
countenanced  by  some  gynecologists. 

Russell,  Lewis,  Bovee,  Goffe,  Eastman,  Richardson,  and  others 
plead  for  early  surgical  intervention. 

Charles  P.  Noble  gives  a  critical  analysis  of  2274  cases  of  uterine 
fibroids.  Two-thirds  of  this  number  were  complicated.  Noble  estimates 
a  prospective  mortality  of  30  per  cent,  in  fibroid  tumors  of  the  uterus 
pursuing  their  natural  course  as  compared  with  an  operative  mortality 
of  2.26  per  cent.  The  high  mortality  in  the  expectant  plan  of  treatment 
is  ascribed  to  degenerations  and  complications  in  the  tumor  and  uterus 
and  to  complications  outside  the  uterus  and  tumors. 

Advantages  of  Early  Operation. — 1.  Lessens  the  hazards  to  life  from 
malignant  degeneration  of  the  tumor  and  uterus. 

2.  Minimizes  the  chances  of  the  development  of  degenerative  changes 
in  the  tumor  which  imperil  life,  also  of  thrombosis  and  embolism. 

3.  Avoids  prolonged  ill  health. 

4.  Lessens  the  operative  mortality. 

5.  Preserves  the  function  of  childbearing. 

Sippel  supports  the  statement  of  Noble  that  operation  is  less  dan- 
gerous than  palliation  by  comparing  the  results  of  47  operated  cases 
in  which  there  were  no  deaths,  with  27  unoperated  cases  in  which  there 
were  6  deaths:  2  from  hemorrhage,  3  from  pulmonary  embolism,  and 
1  from  bronchitis. 

The  menopause  does  not  provide  immunity  from  the  evil  effects  of 
fibroids;  on  the  contrary,  the  dangers  increase  with  age. 

Winter  bases  his  decision  as  to  the  indication  for  operation  upon 
the  symptomatology,  and  does  not  operate  in  the  absence  of  symptoms 
caused  by  the  fibroid  or  by  complicating  lesions.  He  believes  that 
all  the  degenerations  and  complications  which  may  prove  dangerous 
will  give  rise  to  symptoms. 

The  author  is  in  accord  with  the  views  of  Winter,  believing  that 
the  rule  should  be  to  operate  only  when  symptoms  arise.  This  implies 
that  all  fibroids,  however  small  and  wherever  located,  should  be  kept 
under  observation,  and  that  they  should  be  operated  upon  as  soon  as 
symptoms  arise. 

Palliative  Treatment. — Fibroids,  with  or  without  complicating  lesions, 
often  give  rise  to  sjTnptoms  requiring  relief.  A  radical  operation  is 
indicated  in  all  such  cases  unless  serious  complications  exist  which 
would  make  operation  hazardous  or  impossible.  In  this  event  palliative 
measures  are  the  only  alternative. 

Relief  from  Hemorrhage. — A  thorough  curettage  with  prolonged  rest 
in  bed  will  most  surely  control  the  hemorrhages.    Howe^-er  depressed 


606  FIBROMYOMA  OF  THE   UTERUS 

the  patient  may  be  as  the  result  of  anemia,  it  is  usually  possible  to 
give  the  necessary  anesthesia  for  the  purpose. 

The  galvanic  current  was  formerly  used  to  control  uterine  hemor- 
rhages, but  it  is  now  largely  discarded. 

Drugs  are  of  slight  value  in  controlling  hemorrhage.  Ergotin  in 
1-  or  2-grain  doses,  given  four  times  a  day,  will  sometimes  afford  relief. 

Relief  from  Pressure. — When  a  myomatous  uterus  is  displaced  back- 
ward, the  pressure  symptoms  may  be  relieved  by  the  insertion  of  tampons 
behind  the  cervix  or  by  the  wearing  of  a  Hodge-Smith  pessary.  When 
the  tumor  is  incarcerated  in  the  small  pelvis,  and  not  adherent,  it  may 
be  elevated  by  careful  manipulations.  This  may  require  an  anesthetic. 
No  great  amount  of  force  should  be  used  in  these  manipulations  for 
fear  of  hemorrhages  from  broken  adhesions  or  pedicle. 

X-rays. — The  .r-rays  promise  to  supplant  surgery  in  many  cases  of 
uterine  fibroids.  By  a  series  of  applications  of  the  rays  to  the  ovaries, 
hemorrhages  have  been  controlled  and  the  tumor  in  time  reduced 
in  size.  This  action  is  due  to  the  atrophic  changes  produced  in  the 
ovaries,  thereby  bringing  on  an  early  menopause.  To  just  what  extent 
the  a--rays  will  prove  effective  in  these  cases  is  not  yet  known,  but  the 
method  is  deserving  of  extended  trial.     (See  page  225.) 

Contra-indications  to  Operation. — While  there  is  no  complication  pre- 
cluding surgical  interference  that  does  not  apply  to  operations  upon 
uterine  fibroids,  there  are  two  conditions  in  particular  which,  because 
of  their  frequency  and  gravity,  deserve  special  mention,  i.  e.,  anemia 
and  incompetent  heart  action.  W^hen  these  conditions  exist  to  a  marked 
degree,  a  course  of  preliminary  treatment  should  precede  the  operation. 

For  the  anemia,  rest  in  bed,  forced  feeding,  massage,  and  blood 
tonics  are  prescribed  until  the  quality  of  the  blood  is  built  up  to  a 
degree  that  will  admit  of  operation.  When  bleeding  continues,  a 
preliminary  curettage  should  be  done,  and,  if  necessary,  the  vagina 
should  be  tightly  packed  with  gauze. 

An  incompetent  heart  demands  rest  until  it  may  be  safely  depended 
upon  to  withstand  the  stress  of  the  operation.  The  patient  is  confined 
to  bed,  the  bowels  regulated  with  mild  laxatives  and  enemata,  the  diet 
is  light  and  nutritious,  and  such  cardiac  stimulants  given  as  will  regulate 
the  force  and  rhythm  of  the  heart  action.  The  blood  pressure  is  a  good 
indication  of  the  heart  force,  and  should  be  taken  at  frequent  intervals. 

Uncomplicated  fibroids  in  extreme  age  would  justify  non-interference 
when  the  same  sort  of  tumor  in  the  uterus  of  a  younger  woman  would 
clearly  suggest  operative  interference. 

Preparatory  Treatment. — Because  of  the  frequency  with  which  heart 
lesions  and  anemia  complicate  fibroids  of  the  uterus,  the  preparation 
of  the  patient  for  operation  may  require  days  and  possibly  weeks. 

In  one  instance  the  author  was  unable  to  control  the  loss  of  blood 
from  a  large  submucous  fibroid  by  the  usual  means  of  curettage,  uterine 
tamponades,  and  rest  in  bed,  and  was  obliged  to  perform  a  supra- 
vaginal hysteromyomectomy  in  the  presence  of  a  blood-count  far 
below  the  standard   of  safety.     The  results  were  gratifying.     Such 


TREATMENT  OF    UTERI XE   FIBROIDS  607 

experiences  are  exceptional,  tliough  it  has  been  tlie  aiitlior's  experience 
that  fibroid  cases  which  have  reached  a  high  degree  of  anemia,  as  a  rule, 
bear  the  operation  welL  On  the  other  hand,  there  is  uncertainty  as 
to  the  behavior  of  the  heart  during  and  after  the  operation.  Acute 
dilatation  may  take  place  several  weeks  after  operation,  and  with 
fatal  results.  Great  caution  must  be  exercised  in  respect  to  the 
heart  in  all  cases  of  uterine  fibroids,  and  particularly  in  those  which 
have  suft'ered  for  some  time  from  loss  of  blood.  The  absence  of  heart 
murmurs  and  of  increase  in  the  area  of  heart  dulness  does  not  fully 
justify  confidence  in  the  integrity  of  the  heart  when  put  to  the  strain 
of  an  operation. 

The  preliminary  preparation  of  the  bowels  and  of  the  field  of  operation 
does  not  differ  from  that  of  other  vaginal  and  abdominal  operations. 
(See  Chapters  XIII  and  XIV.) 

Choice  of  Operation. — AYhether  the  tumor  shall  be  removed,  leaving 
the  uterus,  or  the  uterus  be  removed  together  with  the  tumor,  is  a 
question  of  great  importance. 

The  number  and  relation  of  the  tumors  to  the  uterine  wall,  as  well  as 
the  existence  of  complicating  lesions,  such  as  carcinoma  of  the  uterus, 
pus-tubes,  and  extensive  pelvic  adhesions,  may  preclude  all  possibility 
of  choice  between  hysterectomy  and  myomectomy.  Excluding  all 
cases  over  forty  years  of  age,  and  all  those  in  which  there  was  no  prob- 
ability of  childbearing  because  of  social  conditions,  Winter  found  the 
following:  LS  myomectomies  for  submucous  fibroids,  4  conceptions 
(22  per  cent.),  37  pregnancies  following  myomectomy,  26  (72.97  per 
cent.)  went  to  term.  46  labors  following  myomectomy,  with  6  abnormal 
labors,  one  of  which  was  attributed  to  the  operation. 

When,  however,  the  statistics  of  various  operators  are  consulted 
and  it  is  learned  that  not  more  than  one  woman  in  ten  on  whom  a 
myomectomy  is  performed  ever  bears  a  child  subsequently,  we  may 
conclude  that  the  question  of  childbearing  should  not  be  considered 
with  hysteromyomectomy.  However,  with  the  facts  clearly  stated 
to  the  patient,  her  wishes  should  be  considered  in  choosing  between 
the  two  operations  when  the  conditions  are  favorable  to  either. 

Against  myomectomy  is  the  possibility  of  leaving  one  or  more  small 
fibroids  which  may  grow  and  cause  trouble  in  later  years.  The  majority 
of  fibroids  are  multiple,  and  it  is  not  possible  to  determine  with  certainty 
that  small  intramural  fibroids  do  not  exist.  The  percentage  of  recur- 
rences is  estimated  at  8  per  cent. 

Unquestionably  a  larger  percentage  of  cases  are  relie\'ed  of  their 
symptoms  through  hysteromyomectomy  than  through  myomectomy. 
According  to  Winter,  73  per  cent,  are  relieved  of  their  symptoms  by 
myomectomy  as  compared  with  97.3  through  hysteromyomectomy. 
We  are  confronted  with  the  question  of  the  artificial  menopause,  with 
its  trend  of  distressing  manifestations,  such  as  flashes  of  heat  and  cold, 
sweating,  despondency,  and  numbness.  These  phenomena,  of  course, 
must  result  from  the  removal  of  the  uterus  and  ovaries,  together  with 
the  tumors.     That  these  symptoms  are  exaggerated  over  those  of  the 


608  FIBROMYOMA  OF  THE   UTERUS 

natural  menopause  is  a  question  upon  which  authorities  do  not  fully 
agree.  In  my  experience  I  have  only  observed  such  cases  in  which 
the  removed  ovaries  were  almost  wholly  degenerated,  and  in  such  cases 
the  menopausal  symptoms  are  not  so  pronounced  as  when  the  ovaries 
were  normal.  However  this  may  be,  it  is  certain  that  the  question 
of  precipitating  the  menopause  should  not  enter  largely  into  the  choice 
between  myomectomy  and  hysteromyomectomy  in  view  of  the  greater 
mortality  of  the  former.  In  submucous  and  subperitoneal  pedunculated 
fibroids,  in  patients  yet  in  the  childbearing  period,  the  choice  may  be 
made  in  favor  of  myomectomy  in  view  of  at  least  preserving  the  hope 
for  childbearing,  even  though  the  chances  are  small.  Finally,  the 
choice  of  operation  must  hinge  upon  the  question  of  the  dangers  involved 
This  is,  after  all,  the  vital  question. 

In  the  hands  of  Winter,  abdominal  myomectomy  gave  a  mortality 
of  9.8  per  cent.,  while  in  supravaginal  hysteromyomectomy  the  mor- 
tality was  but  4.8  per  cent.  Kelly  reported  306  myomectomies,  with 
a  mortality  of  4.5  per  cent.,  and  691  hysteromyomectomies,  with  a 
mortality  of  3.1  per  cent. 

Rules  Governing  the  Choice  of  Operation. — The  following  rules  govern- 
ing the  choice  of  the  several  operative  procedures  may  be  safely  adopted : 

1.  Subserous  and  submucous  pedunculated  fibroids  should  be 
removed  by  myomectomy. 

2.  Necrotic  submucous  pedunculated  fibroids  should  be  removed 
by  vaginal   myomectomy. 

3.  Necrotic  submucous  pedunculated  fibroids  should  be  first  removed 
by  myomectomy,  and  if  other  fibroids  exist  in  the  body  of  the  uterus 
these  should  be  removed,  together  with  the  uterus,  at  a  later  date. 

4.  Fibroids  complicated  by  malignancy  of  the  fibroid  or  uterus 
demand  panhysterectomy. 

5.  The  choice  between  supravaginal  amputation  of  the  uterus  and 
panhysterectomy  may  be  determined  as  follows: 

(a)  If  the  cervix  is  diseased,  perform  a  panhysterectomy. 

(b)  If  malignancy  exists  in  the  cervix,  corpus,  or  tumor,  panhyster- 
ectomy should  be  performed. 

(c)  If  drainage  is  desired,  the  removal  of  the  cervix  will  be  advisable, 
though  not  essential. 

(d)  In  all  other  cases  supravaginal  amputation  will,  as  a  rule,  give 
better  immediate  and  remote  results. 

The  rare  occurrence  of  cancer  in  the  stump  of  the  cervix  is  no  argu- 
ment against  supravaginal  amputation,  in  view  of  the  greater  safety 
of  the  operation. 

Relative  Frequency  of  Operations. — The  following  are  the  statistics 
compiled  by  Charles  P.  Noble  from  his  case  records: 

Abdominal  supravaginal  hysterectomies  .      . 235 

Abdominal  panhysterectomies 14 

Abdominal  myomectomies 22 

Removal  of  ovaries,  etc 15 

Vaginal  hysterectomies                               7 

Vaginal  myomectomies                    44 

Total 337 


OPERATIONS  FOR   UTERINE  FIBROIDS  609 

Kelly  favors  myomectomy  to  a  greater  degree  than  does  Noble. 
In  997  operations  for  fibroids,  306  were  myomectomies  and  691 
hy  steromy  omectomies . 

A  Plea  for  the  Preservation  of  the  Ovaries  in  Operating  for  Fibroids 
of  the  Uterus. — Should  the  ovaries  be  removed  together  with  a  myomatous 
uterus  f 

The  consensus  of  opinion  is  in  favor  of  conserving  the  ovaries,  or  as 
much  of  them  as  is  possible.  We  have  the  statement  of  Zweifel  that 
the  artificially  induced  menopause  causes  more  suffering  than  does  the 
natural  one.  He  therefore  endeavors  to  leave  one  or  both  ovaries. 
Olshausen,  Werth,  Rosthorn,  and,  in  fact,  most  of  the  authorities 
assume  a  like  position. 

The  author  is  in  full  accord  with  these  views  because  experience 
has  proved  that  the  disturbances  incident  to  the  induced  climacterium 
are  greatly  minimized  by  allowing  one  or  both  ovaries  to  remain. 
The  ovaries  should  be  dealt  with  according  to  their  own  merits.  Every 
portion  of  healthy  ovarian  tissue  should  be  conserved.  Bland  Sutton 
has  rightly  said,  "The  ovaries  are  of  more  importance  to  a  M^oman 
than  the  uterus." 

The  author  would  go  one  step  farther  and  advise  the  removal  of  only 
what  is  necessary  of  the  uterus.  When  the  fibroid  is  located  upon 
the  fundus  it  may  be  possible  to  remove  the  tumor  and  fundus  and 
still  preserve  much  of  the  uterus.  This  the  author  did  recently, 
and  to  the  satisfaction  of  the  patient,  who  continues  to  menstruate. 
Unfortunately  the  tumors  are  seldom  so  favorably  situated. 

Operations  for  Uterine  Fibroids. — Vaginal  Myomectomy. — iVll  oper- 
ators agree  that  a  pedunculated  submucous  fibroid,  uncomplicated 
by  fibroid  tumors  located  elsewhere  or  by  other  pelvic  lesions  demand- 
ing relief,  should  be  removed  per  vaginam  and  without  sacrificing  the 
uterus. 

The  scope  of  vaginal  myomectomy  has  been  extended  by  various 
operators  to  the  removal  of  interstitial  and  subperitoneal  fibroids  of 
a  size  not  to  exceed  that  of  the  head  of  a  fetus  at  term,  but  there  are 
serious  objections  to  such  a  procedure.  In  the  first  place  the  operation 
may  prove  difficult.  Again,  there  is  the  vmcertainty  of  the  possible 
presence  of  other  fibroids  lying  within  the  wall  of  the  uterus,  and  of 
the  existence  of  other  pelvic  lesions  which  would  be  recognized  in  an 
abdominal  operation. 

The  author  does  not  look  with  favor  upon  vaginal  myomectomy  for 
fibroids  other  than  when  pedunculated  and  submucous.  This  opinion 
has  no  more  than  a  general  application,  because  unquestionably  there 
are  cases  in  which  the  scope  of  the  operation  may  be  extended  to 
interstitial  and  subperitoneal  fibroids.  For  this  reason  the  technic 
of  the  operation  will  be  presented  in  its  widest  scope. 

hidications  for  Vaginal  Myoviedomy. — 1.  Pedunculated  submucous 
fibroids  of  whatever  size. 

2.  Single  sessile  submucous  fibroids  of  a  size  not  to  exceed  12  cm. 
in  diameter.  The  operation  should  be  preferred  to  supravaginal  hystero- 
39 


610  FIBROMYOMA  OF  THE   UTERUS 

myomectomy  only  when  it  is  desired  that  the  capacity  for  childbearing 
be  safeguarded. 

3.  Single  intramural  fibroids  of  small  size  may  be  removed  through 
an  anterior  or  posterior  colpotomy. 

4.  Small  and  moderate-sized  subperitoneal  fibroids  may  be  removed 
either  by  anterior  or  posterior  vaginal  celiotomy.  The  author's  prefer- 
ence is  for  abdominal  myomectomy  in  such  cases. 

5.  Small  and  moderate-sized  fibroids  of  the  cervix. 

6.  Infected  submucous  fibroids. 

Contra-indications  for  Vaginal  Myomectomy. — The  limitations  of 
vaginal  myomectomy  are  largely  determined  by  the  size,  number, 
and  position  of  the  tumor.  In  the  practice  of  the  author,  vaginal 
myomectomy  is  only  adapted  to  the  removal  of  infected  submucous 
fibroids,  and  of  cervical  fibroids  of  whatever  size,  and  of  uninfected 
submucous  fibroids  of  small  and  moderate  size.  In  all  other  instances 
he  prefers  the  abdominal  route.  That  there  are  greater  possibilities 
for  the  operation  is  admitted  (for  indications  vide  swpra),  but  in  the 
author's  opinion  they  are  ill  advised. 

It  may  be  laid  down,  as  a  general  rule,  that  pelvic  complications, 
of  whatever  nature,  so  long  as  they  require  operative  interference, 
should  determine  the  choice  of  approach  in  favor  of  the  abdominal 
route,  or  a  combination  of  the  vaginal  and  abdominal  routes. 

Technic  of  Vaginal  Myomectomy. — For  pedunculated  fibroids  pro- 
truding from  the  cervix  or  attached  to  the  vaginal  portion  of  the  cervix 
no  anesthetic  is  required.  For  all  other  cases  a  general  anesthetic  is 
desirable.  The  usual  preparation  for  vaginal  operations  is  made.  (See 
page  246.) 

Pedunculated  Siibmucous  Fibroids. — When  the  cervix  is  dilated  and 
the  tumor  presents  in  the  vagina,  the  growth  is  grasped  by  a  heavy 
vulsellum  forceps  and  is  twisted  from  its  attachment.  If,  by  traction 
upon  the  tumor,  the  pedicle  can  be  reached  with  sharp-pointed  scissors, 
it  may  be  severed  without  fear  of  serious  loss  of  blood.  When  there 
is  partial  inversion  of  the  fundus,  associated  with  the  fibroid,  care  must 
be  exercised  in  excising  the  tumor  for  fear  of  injuring  the  inverted  wall 
of  the  uterus. 

If  the  cervix  is  not  dilated  or  the  tumor  is  large  and  wedged  in  the 
cavity  of  the  cervix,  or  the  body  of  the  uterus,  it  will  be  necessary  to 
perform  hysterotomy.  This  is  done  by  bisecting  the  cervix  laterally 
or  anteroposteriorly. 

Sessile  Submucous  Growths. — For  the  removal  of  sessile  submucous 
growths,  hysterotomy  should  be  performed.  The  tumor  is  grasped  by 
heavy  vulsellum  forceps,  the  capsule  is  incised  about  the  base  of  the 
tumor,  when  with  firm  traction  the  tumor  can,  as  a  rule,  be  delivered. 
If  the  tumor  is  too  large  for  delivery  it  may  be  divided  into  two  or 
more  pieces.  All  remaining  fragments  of  the  capsule  are  to  be  trimmed 
off  with  scissors,  leaving  as  smooth  a  surface  as  possible.  The  cavity 
of  the  uterus  should  not  be  curetted  or  irrigated  for  fear  of  puncturing 
the  uterus  and  washing  the  fluid  into  the  abdominal  cavit\'.    After  the 


Vaginal  tysteromyomectomv  f 

^Atter  Doederlein  and  Kroenig.)  -^^entoneal  cavity  opened  in  front  of 

hemorrhage  and  t 

Thereafter  dai,,  vagi^^doX  7S„T":*,o''o7'"''  '"'^^*'°"- 

J  -I  i-u  tuuu,  are  given. 


612 


FIBROMYOMA  OF  THE  UTERUS 


Hysterotomy  Followed  by  Vaginal  Myomectomy.— ^\hen  found 
impossible  to  deliver  a  submucous  fibroid  through  the  cervix,  the 
uterus   must   be   incised.    The  rule  is  to  so  incise  the  cervix  as  to 


Fig.  400 


Vaginal  hysterectomy  for  an  interstitial  fibroid  of  the  body  of  the  uterus.  Fundus  ef  the  uterus 
brought  forward  through  the  anterior  incision.  Ligatures  placed  about  the  appendages  and  broad 
ligaments,  passing  from  above  downward.     Step  2. 

best  expose  the  attachment  of  the  tumor.  The  line  of  choice  is  the 
anterior  median,  but  the  posterior  median  or  bilateral  incisions  are 
often  chosen. 


OPERATIOXS   FOR    UTERIXE  FIBROIDS 


613 


The  author's  preference  is  for  either  an  anterior  or  posterior  incision, 
or  a  combination  of  the  two,  for  the  reason  that  there  is  less  likeHhood 
of  hemorrhage.  More  than  this,  when  it  is  necessary  to  extend  the 
incision  beyond  the  limits  of  the  vaginal  portion  of  the  cervix,  the 


^'aginal  hysterectomy  for  an  interstitial  fibroid  of  the  bodj-  of  the  uterus.     Final  ligature  placed 
about  the  base  of  the  broad  Ugament.     Step  3. 


median  incision  can  be  lengthened  to  any  desired  extent  by  extending 
the  incision  through  the  supravaginal  portion  of  the  cervix  in  front  or 
behind,  or  both.  This  incision  may  or  may  not  involve  the  peritoneal 
cavity.    When  firm  traction  is  made  upon  the  cervix,  but  slight  bleeding 


614 


FIBROMYOMA  OF  THE   UTERUS 


is  occasioned  by  the  incision.     After  the  removal  of  the  tumor  the 
incisions  are  closed  by  continuous  chromicized  catgut  sutures. 


Fig.  402 


Vaginal  hj-sterectomy  for  an  interstitial  fibroid  of  the  body  of  the  uterus.     Uterus  severed  from 
its  attachment  to  the  posterior  vaginal  wall.     Step  4. 


Vaginal  Celiotomy.- — For  the  removal  of  intramural  and  subperitoneal 
fibroids  through  the  vagina  an  anterior  vaginal  celiotomy  is  performed. 


OPERATIONS  FOR   UTERINE  FIBROIDS 


615 


The  uterus  is  drawn  down  into  the  vagina  by  means  of  a  vulsellum 
forceps  and  the  tumor  removed  in  accordance  with  the  principles  laid 
down  above.  In  all  such  cases  the  author's  preference  is  for  abdominal 
myomectomy  or  hysteromyomectomy. 


Fig.  403 


m-'^ 


Vaginal  hysterectomy  for  an  interstitial  fibroid  of  the  body  of  the  uterus.     Stumps  of  ligaments  and 
tubes  anchored  to  the  vault  of  the  vagina.     Peritoneum  stitched  to  the  vaginal  walls.     Step  5. 

Noble  recommends  suturing  the  vesical  fold  of  peritoneum  above 
the  closed  wound  in  the  uterus,  when  the  tumor  has  been  removed 
from  the  anterior  surface,  in  order  to  lessen  the  dangers  of  hemorrhage 
and  septic  peritonitis.  If  the  tumor  is  removed  from  the  posterior 
surface  of  the  uterus,  a  gauze  drain  is  placed  in  the  cul-de-sac  for  like 
reasons.    The  vagina  should  be  lightly  tamponed  with  iodoform  gauze. 


G16  FIBROMYOMA  OF  THE   UTERUS 

Fig.  404  Fig.  405 


^'aginal  hysterectomy  for  an  interstitial  fibroid  of  Splitting  of  the  uterus  in  vaginal   hysterec- 

the   body   of   the    uterus.    Closure  of   the   vaginal      tomy.        Step     2.        (After     Doederlein     and 
walls  with  interrupted  catgut  sutures.     Step  6.  Kroenig.) 


OPERATIONS  FOR   UTERINE  FIBROIDS 


617 


When  the  uterus  is  large  it  will  be  found  easier  to  split  the  uterus 
before  attempting  to  remove  it.     (See  Figs.  405,  406,  and  407.) 


Fig.  407 


Splitting  of  the  uterus  in  vaginal  hystereetomj^.     Step  3. 

Abdominal  Myomectomy. — Before  proceeding  with  an  abdominal 
myomectomy  the  uterus  should  be  curetted  and  irrigated  with  sterile 
normal  salt  solution.  This  is  advised  in  view  of  the  possible  opening  into 
the  uterine  cavity  in  the  enucleation  of  the  tumor,  and  of  the  possibility 
of  substituting  a  supravaginal  hysteromyomectomy  for  myomectomy. 

Indicatio7is. — Pedunculated  Suhperitoneal  Fibroids. — A  wedge-shaped 
incision  at  the  attachment  of  the  pedicle  to  the  uterus  and  the  closure 
of  the  wound  with  No.  2  plain  catgut  sutures  will  complete  the 
operation.  No  raw  surfaces  are  to  be  left  to  invite  the  formation  of 
adhesions. 

Sessile  Subperitoneal  and  Intramural  Fibroids. — Every  possible  pre- 
caution must  be  taken  to  guard  against  infection  of  the  wound  made 
in  the  uterus.  Rubber  gloves  should  be  w^orn,  and  after  delivering  the 
uterus  and  tumors  through  the  abdominal  incision,  a  sterile  towel 
should  be  packed  about  the  edges  of  the  wound  to  protect  the  field 
of  operation  from  the  skin  surface  of  the  abdomen  incision. 

A  straight  incision  is  made  over  the  convexity  of  the  tumor.  The 
extent  of  the  incision  is  measured  by  the  diameter  of  the  tumor. 
The  muscularis  is  reflected  from  the  tumor,  the  tumor  is  grasped  by 
a  vulsellem  forceps,  and  while  firm  traction  is  made  upon  the  tumor, 


618 


FIBROMYOMA  OF  THE   UTERUS 


the  enucleation  is  proceeded  with  by  means  of  the  handle  of  a  knife, 
the  blunt  blades  of  scissors,  or  an  enucleator  especially  designed  for 
this  purpose. 

To  facilitate  the  removal  of  large  and  deep-seated  tumors  it  may 
be  found  advisable  to  bisect  the  tumor  and  enucleate  either  half 
separately. 

Fig.  408 


Myomectomy.  Removal  of  an  interstitial  fibroid  from  the  fundus  of  the  uterus.  Fundus  grasped 
by  a  tenaculum  forceps  and  delivered  through  the  abdominal  incision.  Step  1.  (After  Doederlein 
and  Kroenig.) 


In  small  and  superficial  growths  there  is  little  loss  of  blood,  but  in 
large  and  deep-seated  growths  it  is  necessary  to  control  the  blood  supply 
to  the  uterus  by  having  an  assistant  firmly  grasp  the  broad  ligaments 
and  supravaginal  portion  of  the  cervix  with  the  hand.  All  spurting 
vessels  should  be  ligated  with  fine,  plain  catgut,  taking  care  to  avoid 
crushing  the  tissues  w^ith  forceps  or  unnecessarily  strangulating  tissues 
in  the  ligature. 

The  cavity  occupied  by  the  tumor  is  obliterated  by  interrupted  sutures 
of  catgut  placed  in  tiers.  Care  must  be  taken  that  no  dead  spaces  are 
left  in  which  blood  may  accumulate  and  that  the  sutures  are  not  tied 
too  tightly.  A  smooth  serous  surface  should  be  left  at  the  line  of  suture, 
otherwise  adhesions  may  form.  A  mattress  suture  is  best  adapted 
for  the  serous  surface. 


OPERATIONS  FOR   UTERINE  FIBROIDS 


619 


Incision  made  over  the  tumor,  including  the  uterine  wall  and  capsule  of  the  tumor.     Tumor 
by  a  tenaculum  forceps.     Step  2. 


Fig.  410 


Obliteration  of  the  cavity  in  the  uterine  wall  by  a  continuous  suture  of  plain  catgut.     Care  exercised 
not  to  leave  dead  spaces  or  to  constrict  the  tissues  too  tightlj'  in  Ugating.      Step  3. 


620 


FIBROMYOMA   OF   THE    UTERUS 


For  the  average  operator  a  supravaginal  hysteromyomectomy  wQl 
yield  better  results  than  the  remo\'al  of  multiple  tumors  from  the 
uterine  wall. 

^lyomectomy  in  deep-seated  fibroids  is  not  an  operation  of  choice 
for  the  average  operator. 

Abdominal  myomectomy  should  never  be  performed  in  the  presence 
of  a  pelvic  infection  or  for  the  removal  of  degenerated  fibroids. 

Abdominal  Myomectomy  for  Submucous  Fibroids-. — When  the  cervix 
is  firmly  contracted  and  the  tumor  is  too  large  to  deliver  per  vaginam, 
abdominal  myomectomy  may  be  considered,  in  view  of  possibly  preserv- 
ing the  function  of  childbearing.  The  abdominal  route  should  not  be 
considered  when  it  is  possible  to  remove  the  tumor  by  morcellation. 
Again,  the  abdominal  route  should  not  be  undertaken  in  the  presence 
of  a  pelvic  infection  resident  within  or  without  the  uterus,  nor  should 
a  degenerated  fibroid  be  removed  through  an  abdominal  incision. 

Fig.  411 


Closure  of  the  uterine  musculature  and  peritoneum  with  a  continuous  suture  of  plain  catgut. 

Step  4. 


As  a  preliminary  measure  the  uterus  should  be  curetted  and 
irrigated  with  sterile  normal  salt  solution.  The  technic  of  the  operation 
does  not  differ  from  that  of  abdominal  myomectomy  in  general.  A 
median  incision  in  the  anterior  wall,  extending  from  the  fundus  to  the 
cervix,  is  preferred. 

Hysteromyomectomy, — 1.  Vagixal  Hysteromyo^^iectomy. — In  the 
judgment  of  the  author  there  are  few  indications  for  vaginal  hystero- 
myomectomy. To  successfully  perform  the  operation  without  encoun- 
tering unusual  difficulties,  the  tumor  and  uterus  should  be  no  larger 
than  a  fetal  head  at  term,  the  structures  to  be  removed  should  be  freelv 


OPERATIONS  FOR   UTERINE  FIBROIDS  621 

movable,  and  the  vagina  should  provide  sufficient  room  to  admit  of 
the  delivery. 

In  the  majority  of  cases,  answering  these  requirements,  myomectomy  or 
abdominal  hysteromyomectomy  would  be  preferred.  When  the  abdomi- 
nal wall  is  thick  and  the  vagina  roomy  a  vaginal  hysteromyomectomy 
may  be  preferred  to  an  abdominal  operation.  Furthermore,  in  infected 
and  sloughing  fibroids  demanding  the  sacrifice  of  the  uterus,  vaginal 
hysteromyomectomy  should  be  the  operation  of  choice.  In  the  presence 
of  a  sloughing  or  impacted  fibroid  it  is  advisable  to  first  remove  the 
tumor  and  await  the  time  when  the  field  of  operation  is  free  of  infection 
before  proceeding  with  a  vaginal  hysterectomy. 

The  technic  of  vaginal  hysteromyomectomy  does  not  differ  from  that 
of  vaginal  hysterectomy  in  its  essential  details.     (See  page  681.) 

2.  Abdominal  Hysteromyomectomy. — The  choice  between  supra- 
vaginal and  total  hysterectomy  should  be  made  in  favor  of  the  former 
whenever  it  is  possible  to  leave  a  healthy  cervix.  The  reasons  for  so 
doing  are  that  the  operation  presents  fewer  technical  difficulties,  requires 
less  time,  there  is  less  danger  of  injuring  the  ureters  and  less  likelihood 
of  creating  a  cystitis  from  injury  to  the  bladder.  Furthermore,  the 
vault  of  the  vagina  is  left  intact. 

When  drainage  is  required  or  the  condition  of  the  cervix  justifies 
its  removal,  and  when  the  tumor  is  so  located  as  to  render  a  supra- 
vaginal amputation  impossible,  total  hysterectomy  is  the  operation  of 
choice. 

I.  Suyravaginal  Hysteromyomectomy. —  Technic. — The  following  steps 
are  taken  in  uncomplicated  cases:  The  abdominal  incision  should 
be  of  such  length  as  to  permit  of  easy  delivery  of  the  tumor.  Care 
should  be  taken  to  prevent  cutting  the  bladder,  which  may  be  found 
much  elevated. 

The  hand  is  passed  over  the  entire  circumference  of  the  uterus  and 
tumors  to  determine  the  size  and  position  of  the  tumor  or  tumors,  to 
locate  the  point  of  amputation,  and  to  detect  and  break  up  existing 
adhesions. 

Delivery  of  the  Tumor  and  Uterus. — -The  tumor  is  delivered  from 
the  abdomen  by  means  of  the  hands  or  vulsellum  forceps.  This  may 
be  found  difficult  and  require  the  aid  of  an  assistant.  When  incar- 
cerated in  the  pelvis,  an  assistant  may  place  two  fingers  in  the  vagina 
and  forcibly  push  the  tumor  upward  in  the  axis  of  the  superior  strait, 
thereby  reinforcing  the  efforts  of  the  operator,  who  is  making  traction 
upon  the  tumor  from  above. 

Immediately  following  the  delivery  of  the  tumor  large  packs  of 
sterile  gauze  should  wall  oft'  the  intestines.  For  this  purpose  the 
author  uses  one  or  two  five-yard  rolls  of  gauze. 

Ligation  and  Severing  of  the  Appendages,  Vessels,  and  Ligaments  on 
Either  Side  of  the  Uterus. — For  ligatures  the  author  is  in  the  habit 
of  using  No.  2  plain  sterile  catgut  passed  on  an  Olshausen  pedicle 
needle.  In  large  fibroids  the  veins  are  often  found  greatly  enlarged, 
hence  the  necessitv  of  exercising  care  in  securing  all  vessels.     The 


622  FIBROMYOMA  OF  THE   UTERUS 

ovarian  and  uterine  arteries  should  be  secured  by  two  separate  liga- 
tures, thus  affording  double  security.  One  linen  and  one  catgut  ligature 
for  these  vessels  will  give  added  security. 

When  the  tubes  and  ovaries  are  normal  there  is  no  good  reason  for 
removing  them.  The  preservation  of  the  ovaries  will  ward  off  the 
nervous  phenomena  of  the  artificial  menopause,  which  is  a  matter  of 
grave   importance. 

The  first  ligature  is  made  to  embrace  the  tube,  ovarian  ligament, 
and  bloodvessels  entering  the  horn  of  the  uterus.  A  second  ligature 
is  passed  immediately  to  the  side  of  the  first.  These  structures  are 
then  severed  between  the  ligatures  and  the  uterine  horn.  The  bleeding 
from  the  uterus  is  controlled  by  an  artery  clamp,  placed  close  to  the 
side  of  the  uterus.  A  ligature  is  tied  about  the  round  ligament  at  its 
proximal  end  and  the  ligament  severed  close  to  the  uterus.  A  single 
ligature  is  next  passed  through  the  broad  ligament  close  to  the  uterus, 
and  will,  as  a  rule,  incorporate  the  tissues  of  the  broad  ligament  to  a 
point  near  the  uterine  artery.  This  portion  of  the  broad  ligament  is 
severed  close  to  the  uterus  and  the  bleeding  from  the  uterus  secured 
by  an  artery  clamp. 

The  process  is  repeated  on  the  opposite  side.  Next  the  peritoneum 
is  stripped  from  the  uterus,  beginning  in  front  at  a  point,  preferably 
about  an  inch  above  the  attachment  of  the-  bladder.  This  incision 
should  only  extend  the  thickness  of  the  peritoneum.  With  a  gauze 
sponge  wrapped  about  the  finger  the  peritoneum  is  stripped  downward 
to  a  point  below  the  proposed  line  of  incision  through  the  cervix. 

With  the  bladder  pushed  downward  and  forward  the  ureters  are 
not  so  liable  to  injury  in  ligating  and  severing  the  uterine  arteries. 
These  arteries  are  ligated  close  to  the  uterus.  Two  ligatures  are 
passed  about  them  and  the  incision  is  made  close  to  the  cervix.  Any 
spurting  vessel  must  be  secured  by  a  separate  ligature. 

A  tenaculum  forceps  is  placed  in  the  cervix  at  a  point  below  the 
proposed  line  of  amputation,  by  which  the  assistant  may  later  hold  the 
stump  of  the  amputated  cervix  under  control.  A  wedge-shaped  incision 
is  made  through  the  cervix  from  before  backward  and  downward  and 
from  behind  forward  and  downward.  The  body  of  the  uterus  and 
tumors  are  then  freed  and  are  passed  to  an  assistant. 

The  next  step  is  to  disinfect  the  cervical  canal,  which  may  be  done 
with  a  swab  of  carbolic  acid  or  pure  formalin,  or  with  a  Paquelin 
cautery. 

The  wedge  in  the  cervical  stump  is  then  closed  with  a  running  suture 
of  No.  2  plain  catgut.  The  stumps  of  the  tubes  and  ligaments  are 
anchored  to  the  lateral  portions  of  the  cervical  stump.  Linen  or  silk 
should  be  used  for  this  purpose. 

Finally,  the  peritoneum  is  closed  over  the  cervix  with  a  running 
suture  of  No.  1  plain  catgut  and  in  a  manner  that  will  leave  a  clean 
floor  of  peritoneum,  free  of  raw  surfaces,  to  which  surrounding  structures 
may  not  adhere.  After  carefully  removing  all  blood  from  the  pelvis  the 
abdomen  is  closed  without  drainage. 


OPERATIONS  FOR   UTERINE  FIBROIDS 


623 


Kelly's  Modification  of  Supravaginal  Hysterectomy. — The  ligaments 
and  appendages  are  severed  on  one  side  and  the  peritoneum  and  bladder 
are  reflected  from  the  anterior  surface  of  the  uterus  as  described  above. 
After  ligating  the  uterine  artery,  Kelly  proceeds  to  amputate  the  cervix 
close  to  the  vault  of  the  vagina.  As  the  amputation  proceeds  the 
assistant  draws  the  uterus  to  the  opposite  side.  As  the  last  fibers  of 
the  cervix  are  severed,  the  uterine  artery  of  the  opposite  side  presents 
and  is  clamped  by  an  assistant  about  an  inch  above  the  cervical  stump. 
By  rolling  the  uterine  body  still  farther  to  the  opposite  side  the  round 
ligament  comes  into  view;  this  is  clamped  at  the  level  of  the  pelvic 
brim  and  severed.     (See  Fig.  418.) 


Fig.  412 


Supravaginal  abdominal  hj-steromyomectomy.     Posterior  aspect. 
below  the  appendages.     Step  1. 


Broad  ligaments  clamped 


This  removes  the  body  of  the  uterus  and  tumors  and  the  remaining 
steps  of  the  operation  are  the  same  as  described  above.  This  operation 
is  particularly  adapted  to  the  removal  of  a  broad  ligament  fibroid. 

When  it  is  necessary  to  remove  the  appendages  of  the  uterus,  the 
only  variation   in  the  above  technic  consists  in  the  ligation  of  the 


624 


FIBROMYOMA  OF  THE   UTERUS 


infundibulopelvic  ligament  in  place  of  the  structures  incorporated  in 
the  first  ligatures  as  above  described. 

II.  Total  Abdominal  Hysteromyomedomy. — The  first  steps  of  the 
operation  are  identical  to  those  of  supravaginal  amputation.  {Vide 
supra.)  These  steps  are  the  ligation  of  the  ovarian  and  uterine  vessels, 
the  separation  of  the  appendages  and  ligaments  close  to  the  uterus  and 
down  to  the  supravaginal  portion  of  the  cervix  and  the  turning  down 
of  the  peritoneal  cuff  and  bladder  on  the  anterior  surface  of  the  uterus. 


Fig.  413 


Broad  ligament  cut  between  clamps  and  uterus.     Ligatures  placed  about  the  uterine  artery.     Ovarian 
ligament,  round  ligament,  and  infundibulopelvic  ligament.     Step  2. 


The  bladder  is  stripped  entirely  from  the  cervix,  exposing  the  vaginal 
wall  as  it  is  reflected  upon  the  cervix.  The  uterus  is  then  drawn  upward 
and  backward  and  a  transverse  slit  is  made  into  the  anterior  vault 
of  the  vagina,  close  to  the  cervix.  This  opening  is  made  with  sharp- 
pointed  scissors  and  is  about  one  inch  in  length.  Before  making  this 
incision  the  vaginal  wall  is  carefully  identified  with  the  finger  and  is 
recognized  by  palpating  the  vaginal  portion  of  the  cervix  through 


OPERATIONS  FOR   UTERINE  FIBROIDS 


625 


it.  If  gauze  had  been  previously  packed  in  the  vagina  it  will  be  felt 
through  the  wall  of  the  vagina  before  making  the  incision. 

The  incision  is  then  extended  around  and  is  made  close  to  the  cervix 
to  avoid  injury  to  the  surrounding  structures,  notably  the  ureters. 
This  completely  frees  the  uterus  from  its  attachments  when  it  is  removed. 

All  bleeding  points  are  temporarily  secured  with  clamps.  The 
peritoneum  posterior  to  the  bladder  is  stitched  to  the  margin  of  the 
anterior  vaginal  flap;  the  broad  ligaments,  round  ligaments,  and  tubes 
are  anchored  with  linen  to  the  outer  angles  of  the  vaginal  opening 
and,  finally,  the  vaginal  walls  and  peritoneum  are  stitched  together 
from  before  backward,  thereby  approximating  the  peritoneum  in  front 
with  that  attached  to  the  posterior  flap  of  vagina. 

Fig.  414 


Peritoneum  and  bladder  reflected  from  the  supravaginal  portion  of  the  cervix.  Body  of  the  uterus 
amputated  at  the  internal  os.  Interrupted  sutures  placed  in  cervical  stump  preparatory  to  closure 
of  the  stump.     Step  3. 


The  completed  operation  leaves  a  smooth  bed  of  peritoneum  at  the 
pelvic  floor,  with  the  ligaments  so  anchored  that  they  prevent  prolapse 
of  the  walls  of  the  vagina. 

If  the  appendages  are  removed  the  severed  edges  of  the  broad  liga- 
ments are  approximated  with  a  running  suture  of  catgut.  For  all 
ligatures  and  sutures  the  author  uses  No.  2  plain  sterile  catgut,  with 
the  addition  of  linen  sutures  to  secure  the  ovarian  and  uterine  arteries 
and  to  anchor  the  ligaments  to  the  vault  of  the  vagina. 
40 


626 


FIBROMYOMA  OF  THE   UTERUS 


Conservation  of  Ovaries  after    Hysterectomy. — It  is  the  experience  of 
Dickinson  that  four-fifths  of  the  patients  from  whom  the  uterus  has 


Fig.  415 


Round  ligaments,  ovarian  ligaments,  and  tubes  anchored  to  the  stump  of  the  cervix  and  a  fold  of 
peritoneum  sutured  over  the  stump  of  the  cervix.     Step  4 

Fig.  416 


Completed  operation  with  the  appendages  removed.    The  pelvic  floor  is  completely  covered 

with  peritoneum. 


been  removed  and  the  ovaries  left  in  situ  are  free  from  the  disturbances 
rof  the  surgical  menopause.    He  finds  better  results  in  this  regard  when 


OPERATIONS  FOR   UTERINE  FIBROIDS  627 

both  ovaries  are  left  than  when  one  is  removed  or  both  are  resected. 
When  the  disturbances  do  occur,  their  character  is  less  severe  and  more 
gradual  than  after  bilateral  removal  of  the  ovaries.  Sexual  vigor  is 
maintained  when  both  ovaries  are  conserved,  but  will  be  lost  at  an 
earlier  time  than  in  the  normal  woman. 

Management  of  Complications  in  Hysteromyomectomy. — The  compli- 
cations of  fibroids  of  the  uterus  are  so  frequent  and  varied  as  to 
present  innumerable  and  oftentimes  serious  difficulties.  It  is  not 
a  difficult  undertaking  to  perform  an  uncomplicated  hysteromyomec- 
tomy, but  the  presence  of  complications  may  require  formidable 
operative  procedures  that  will  tax  the  skill  of  the  most  expert  operator. 

The  following  classification  of  complications  as  enumerated  by  Kelly 
present  a  formidable  array: 

1.  Adhesions  and  Affections  of  Surrounding  Strjictures. — (a)  Inflam- 
matory.— Peritoneal  adhesions  frequently  bind  the  tumor  and  the 
uterus  and  its  appendages  to  the  surrounding  structures.  These  vary 
in  extent  and  firmness.  So  far  as  possible  they  are  to  be  severed  by 
the  fingers;  thus  the  utmost  caution  must  be  exercised  to  prevent 
injury  to  adherent  structures,  notably  the  bowel,  bladder,  and  impor- 
tant bloodvessels.  When  the  appendages  are  inaccessible  through 
overhanging  tumor  growths  and  the  embedding  of  the  tube  and  ovary 
in  firm  adhesions  on  the  floor  of  the  pelvis,  it  may  be  found  advisable, 
as  Kelly  has  pointed  out,  to  at  first  ligate  and  sever  the  ovarian  vessels 
at  the  outer  extremity  of  the  broad  ligaments,  and  to  tie  and  sever  the 
round  ligaments  at  their  uterine  attachment.  This  opens  up  the  top 
of  the  broad  ligament  when  the  uterus  can  be  lifted  to  the  opposite  side, 
thereby  giving  better  access  to  the  appendages.  AYhen  the  adhesions 
are  far  more  extensive  on  one  side,  and  particularly  when  accumulations 
of  pus  are  to  be  dealt  with,  it  is  best  to  adopt  the  Kelly  modification, 
by  severing  the  attachments  on  the  opposite  side  and  removing  the 
uterus,  when  the  infiammatory  mass,  together  with  the  abscess,  may 
be  removed  with  comparative  ease. 

Whenever  pus  is  suspected  great  care  should  be  exercised  in  walling  oft' 
the  abdominal  cavity  with  sterile  pads  before  disturbing  the  adhesions. 
When  pus  is  encountered  it  must  be  aspirated  or  carefully  swabbed 
out  before  proceeding  with  the  further  steps  of  the  operation.  A  careful 
toilet  of  the  peritoneum  must  be  made  with  sponges,  fresh  sterile  gauze 
packs  should  be  placed  about  the  field  of  operation,  and  the  gloves  of 
the  operator  and  assistant  changed.  In  such  cases  a  complete  hyster- 
ectomy is  preferred  to  supravaginal  amputation,  for  the  reason  that 
drainage  can  be  more  readily  established  through  the  vagina. 

The  omentum,  containing  large  bloodvessels,  may  be  adherent  to 
the  tumor  and  require  resection  before  proceeding  with  the  removal 
of  the  uterus.  Adhesions  between  bowel  and  tumor  most  often  in^'olve 
the  sigmoid,  less  frequently  the  rectum  and  cecum,  and  rarely  the  small 
bowel.  These  can  usually  be  readily  separated  with  the  fingers,  but 
when  they  are  closely  adherent  it  is  safest  to  remove  the  tumor  capsule, 
leaving  it  attached  to  the  bowel. 


628 


FIBROMYOMA  OF  THE  UTERUS 


An  appendix  adherent  to  the  tumor  requires  careful  manipulation. 
If  the  adhesions  are  light  the  separation  presents  no  difficulties,  but 
when  they  are  dense  it  is  best  to  remove  the  appendix,  together  with 
the  adhesions.  The  Kelly  modification  of  removing  the  uterus  and 
tumors  from  left  to  right  is  applicable  in  these  cases. 

(b)  Tumors  and  other  swellings  of  the  ovary,  when  large,  should  be 
removed  before  proceeding  with  the  uterus.  "V^^len  of  small  size  the 
entire  mass  should  be  removed  together. 

(c)  Carreer  of  the  cervix  and  corpus  complicating  uterine  fibroids 
require  panhysterectomy. 

2.  Complications  Due  to  Changes  in  the  Tumors  Themselves. — All  sorts 
of  degenerative  processes  in  myomatous  tumors  (see  page  586)  are 
dealt  with  on  the  general  principle  laid  down  for  the  classical  operations 
of  supravaginal  and  panhysterectomy. 


Fig.  417 


Fibroid  in  anterior  wall  of  the  uterus,  elevating  the  bladder. 


3.  Compjlicaiions  Due  to  the  Location  of  the  Tumors. — ^Myomatous 
tumors  may  be  so  located  as  to  present  a  formidable  problem  to  the 
operator.  They  may  be  so  located  as  to  crowd  the  bladder,  ureters, 
sigmoid,  and  uterus  quite  out  of  their  normal  relations,  so  that  the 
usual  landmarks  are  obscured. 

"When  the  tumor  is  large  and  occupies  the  body  of  the  uterus,  making 
it  difficult  to  recognize  and  to  ligate  the  broad  ligaments  which  are 
drawn  in  a  vertical  direction  close  to  the  brim  of  the  pelvis,  it  is  advised 
by  Kelly  to  bisect  the  uterus  and  remove  each  half  separately.  When 
possible  a  long  forceps  or  sound  should  be  passed  through  the  uterine 
canal  to  serve  as  a  guide.    Without  this  guide  there  is  danger  of  carrying 


OPERATIONS  FOR   UTERINE  FIBROIDS 


629 


the  incision  into  the  uterine  vessels.  Considerable  bleeding  may  be 
encountered  and  require  the  free  use  of  forceps  until  the  uterine  vessels 
can  be  secured. 

Again,  it  may  be  possible  to  gain  room  and  thereby  facilitate  the 
operation  by  first  enucleating  the  fibroid,  after  which  the  uterus  can 
be  removed. 

Large  tumors  lodged  beneath  the  vesical  peritoneum  may  expose 
the  bladder  to  injury  in  opening  the  abdomen.  To  avoid  this  accident, 
the  peritoneum  should  be  opened  at  the  upper  limit  of  the  incision  and 
the  incision  enlarged  downward.  Kelly  advises  to  first  tie  off  the  left 
ovarian  bloodvessels,  then  to  cut  with  scissors  the  peritoneum  from 
round  ligament  to  round  ligament,  this  to  be  followed  by  deflection 
of  the  peritoneum  and  bladder  when  the  uterine  vessels  are  exposed 
and  tied. 

Fig.  418 


Supravaginal  hysteromyomectomy.     Body  of  uterus  amputated  from  left  to  right.     (After  Kelly.) 

Broad  Ligament  Fibroids. — The  great  danger  in  the  removal  of 
broad  ligament  fibroids  lies  in  the  possible  injury  to  the  ureters.  The 
displacement  of  the  ureter  by  broad  ligament  fibroids  of  large  size 
may  be  such  as  to  mislead  the  most  experienced  operator. 

In  removing  a  large,  broad  ligament  fibroid  the  sigmoid  must  be 
carefully  freed,  so  as  to  expose  the  ovarian  vessels;  these  are  ligated 
and  severed  at  the  periphery  of  the  tumor.  The  round  ligament  is 
ligated  and  severed  near  to  the  uterus,  and  the  two  points  are  connected 
by  an  incision  made  with  scissors  through  the  peritoneum  over  the 
circumference  of  the  tumor.     The  peritoneum  is  then  stripped  from 


630  FIBROMYOMA  OF  THE   UTERUS 

the  tumor,  the  tumor  grasped  with  a  heavy  vulsellum  forceps  and 
dissected  from  its  bed  of  celhilar  tissue.  The  uterine  vessels  are  now 
exposed  and  Hgated  near  the  uterus,  taking  care  to  avoid  injury  to 
the  uterus.  The  body  of  the  uterus  is  then  amputated  at  the  internal 
OS,  and  from  this  point  the  operation  proceeds  in  the  usual  manner. 

Combined  Submucous  and  Corporeal  Tumors. — When  there  has  been 
bleeding,  making  complete  extirpation  of  the  uterus  hazardous,  it  is 
advisable  to  first  remove,  per  vaginam,  the  submucous  growth  and, 
at  a  later  date,  when  the  patient's  strength  is  restored,  to  remove 
the  uterus,  together  with  the  corporeal  tumors.  The  same  method 
should  be  adopted  w^hen  the  submucous  growth  is  necrotic. 

If  the  strength  of  the  patient  will  permit,  and  degenerative  changes 
are  absent  in  the  submucous  growth,  the  entire  tumor  mass  and  uterus 
may  be  removed  eji  masse  through  the  abdomen. 

Fibroids  Complicating  Pregnancy,  Labor,  and  the  Puerperium. — 
Frequency  of  Fibroids  Complicating  Pregnancy. — Pinard  found  84  cases 
in  14,000  pregnancies.  Klinik  Baudelocque  had  85  cases  in  13,813 
pregnancies.  It  is  probable  that  a  larger  unrecognized  percentage 
exists. 

Influence  of  Pregnancy  on  Fibroids. — The  rule  is  that  fibroids  grow 
rapidly  during  the  period  of  pregnancy.  The  rate  of  growth  is  pro- 
portionate to  the  vascularity  of  the  tumor  and  to  the  intimacy  of  the 
tumor  to  the  uterus.  Hence  it  follows  that  interstitial  fibroids  commonly 
take  on  a  rapid  growth  while  pedunculated  subperitoneal  fibroids 
usually  grow  slowly,  if  at  all.  The  increase  in  size  is  largely  due  to 
edema  of  the  tumor  and,  to  a  lesser  degree,  to  true  hypertrophy  or  other 
forms  of  degeneration  of  the  tumor  substance.  Necrotic  changes 
rarely  develop  in  pregnancy,  but  are  common  in  the  puerperium.  The 
form  of  necrosis  is  usually  suppuration  or  gangrene.  After  such  an 
event  a  submucous  fibroid  may  be  expelled  from  the  uterus,  and  sub- 
peritoneal fibroids  have  been  known  to  slough  through  the  bladder, 
vagina,  rectum,  and  abdominal  wall. 

Influence  of  Fibroids  on  Pregnancy. — Pregnancy,  labor,  and  the 
puerperium  may  proceed  without  alteration  in  the  presence  of  a  uterine 
fibroid,  but,  on  the  other  hand,  serious  complications  may  arise.  The 
influence  of  a  fibroid  tumor  upon  the  pregnant  uterus  is  largely  deter- 
mined by  the  size  and  position  of  the  growth. 

1.  Fibroids  of  the  Cervix. — Fibroids  of  the  cervix  do  not  seriously 
embarrass  the  development  of  the  pregnant  uterus,  but  may  interfere 
with  the  engagement  of  the  presenting  part  and  with  the  delivery  of 
the  fetus  and  placenta.  The  cervix  may  fail  to  dilate  in  the  presence 
of  a  fibroid  tumor  of  the  cervix.  These  embarrassments  may  be  relieved 
by  the  protrusion  of  the  tumor  through  the  cervix  or  the  spontaneous 
disengagement  of  the  tumor  when  it  is  submucous.  Subserous  tumors 
may  become  pedunculated  and  rise  out  of  the  pelvis,  or  they  may 
soften  from  edema  and  so  flatten  out  as  to  permit  the  passage  of  the 
child. 

2.  Fibroids  of  the  Body  of  the  Uterus. — Fibroids  of  the  body  of  the 
uterus  do  not  permit  of  the  development  and  distention  of  the  uterine 


TREAT  ME  XT  631 

musculature  at  the  seat  of  the  tumor;  this  leads  to  a  compensatory 
thickening  in  the  surrounding  musculature.  As  a  consequence  the 
uterine  contractions  are  embarrassed,  labor  is  prolonged,  and  post- 
partum hemorrhages  are  liable  to  occur.  Large  fibroids  distort  the 
uterine  cavity  and  lead  to  malpositions  and  malpresentations  of  the 
fetus.  Malformations  of  the  fetus  are  the  possible  result  of  large  sub- 
mucous and  interstitial  fibroids.  Great  difficulty  may  be  experienced 
in  delivering  the  placenta  when  it  is  implanted  above  a  protruding 
fibroid.  In  such  an  event  sepsis  and  postpartum  hemorrhages  are 
the  possible  consecpences.  Wenkel  estimates  that  placenta  preevia 
occurs  in  3.4  per  cent,  of  all  cases  of  fibroids  complicating  pregnancy, 
and  adherent  placentae  are  of  frequent  occurrence.  Interference  with 
free  drainage  of  the  lochia  may  result  from  an  obstructing  fibroid. 

Subserous  tumors  may  be  incarcerated  or  adherent  in  the  pelvis 
in  such  a  manner  as  to  prevent  the  development  of  the  pregnant  uterus. 
In  such  an  event  pregnancy  would  have  to  be  terminated.  Hemorrhage, 
ileus,  ischuria,  uremia,  hydronephrosis,  pyonephrosis,  and  rupture  of 
the  uterus  are  occasional  complications  arising  out  of  the  presence  of 
a  fibroid  in  the  body  of  the  uterus.  Fibroids  often  diminish  in  size, 
and  in  rare  instances  wholly  disappear  after  the  end  of  the  puerperium. 
This  fortunate  outcome  is  not  to  be  anticipated  because  of  its  unusual 
occurrence. 

Treatment. — Xo  definite  rules  can  be  formulated  for  the  management 
of  these  cases  because  the  uterus,  fetus,  and  tumor  present  themselves 
under  such  varying  conditions. 

1.  No  interference  is  demanded  in  70  to  SO  per  cent,  of  cases. 

2.  Subperitoneal  fibroids,  causing  pressure  sjTnptoms,  may  some- 
times be  elevated  hy  bimanual  mani-pulations  and  the  pregnancy  proceed 
to  term.  When  this  cannot  be  done  an  abdominal  section  is  preferred  to 
the  induction  of  abortion. 

3.  The  induction  of  abortion  is  not  looked  upon  with  favor  because 
of  the  great  liability  of  hemorrhage  and  infection  and  the  certainty 
of  leaving  a  tumor  which  will  subsequent!}'  demand  operative  inter- 
ference.   It  is  better  to  accomplish  both  at  the  same  time. 

4.  Myomectomy. — Only  pedunculated  submucous  and  subperitoneal 
fibroids  justify  myomectomy.  Even  under  the  most  favorable  con- 
ditions there  is  great  liability  to  miscarriage.  Under  no  circumstances 
should  a  fibroid  be  shelled  out  of  the  wall  of  a  pregnant  uterus. 

Myomectomy  immediately  followed  by  the  induction  of  abortion  is 
hazardous  because  of  the  dangers  of  rupture  of  the  uterus,  hemorrhage, 
and  infection. 

Cesarean  Section. — ^Yhen  the  child  is  at  or  near  term  and  the  fibroid 
tumors  are  of  such  size  and  location  as  to  justify  the  sacrifice  of  part 
or  all  of  the  uterus,  a  classical  Cesarean  section  should  be  performed 
and  the  uterus  removed.  Care  must  be  taken  to  a^oid  cutting  through 
the  tumor  in  removing  the  fetus. 

The  Porro  operation  is  preferred  to  Cesarean  section  when  the  uterus 
is  believed  to  be  infected.  The  location  of  the  tumor  will  generally 
determine  the  choice  between  supravaginal  and  total  hysterectomy. 


CHAPTER    XXVIII 
CARCINOMA  AND   SARCOMA  OF  THE  UTERUS 

Cakcinoma  of  the  Uterus  Treatment   of   Cancer   of   Cervix 

Topographical  Classification  Complicating  Pregnancy 

Etiology  Treatment  of  Inoperable  Cancer 

Anatomical  Diagnosis  of  Cervix 

Clinical  Diagnosis  Treatment  of  Cancer  of  Body  of 

Microscopic  Diagnosis  Uterus 

Differential  Diagnosis  Endothelioma 
Diagnosis  of  Extension                      Sarcoma  of  the  Uterus 

Treatment  Etiology 

Operative  Treatment  Anatomical  Diagnosis 

Simple  Vaginal  Hysterectomj'  ^licroscopic  Diagnosis 

BjTne  IMethod  Clinical  Diagnosis 

Schuchardt  Operation  Prognosis 

Radical  Abdominal  Operation  Treatment 

CARCINOMA  OF  THE  UTERUS 

Topographical  Classification. — Carcinoma  may  arise  from  any  por- 
tion of  the  uterine  mucosa,  both  within  the  uterus  and  covering  the 
vaginal  portion  of  the  cervix.  The  classification  proposed  by  Ruge 
and  Veit  is  as  follows: 

1 .  Carcinoma  of  the  vaginal  portion  of  the  cervix,  including  the  vaginal 
surface  of  the  cervix  from  the  external  os  to  the  vault  of  the  vagina. 

2.  Carcinoma  of  the  cervix,  including  the  mucosa  of  the  cervical  canal. 

3.  Carcinoma  of  the  body  of  the  uterus,  including  the  mucosa  from  the 
internal  os  to  the  horns  of  the  uterus. 

It  will  be  observed  that  the  location  of  the  newgrowth  is  not  only 
of  pathological  interest  but  has  much  to  do  with  the  manner  of 
diagnosis,  the  clinical  manifestations,  prognosis,  and  treatment. 

Etiology. — The  essential  cause  of  carcinoma  is  as  yet  unknown. 
Certain  predisposing  causes  are  well  recognized  and  require  consider- 
ation. 

Age. — W^e  find  carcinoma  of  the  uterus  commonly  appearing  about 
the  time  of  the  menopause.  Carcinoma  of  the  vaginal  portion  more 
often  makes  its  appearance  immediately  preceding  the  menopause, 
and  carcinoma  of  the  body  usually  appears  a  few  months  or  years 
later.  The  earliest  recorded  case  appeared  at  eight  years  of  age. 
The  author  observed  a  case  of  carcinoma  of  the  vaginal  portion 
in  a  woman,  aged  ninety-three  years,  forty-eight  years  after  the 
menopause.  The  greatest  number  appear  between  forty  and  fifty 
years  of  age. 


ETIOLOGY  '  633 

In  3385  cases  of  cancer  of  the  uterus  Gusserow  found  but  two  origi- 
nating before  twenty  years  of  age. 

Heredity. — Heredity,  while  playing  an  important  role,  is  of  less  im- 
portance as  an  etiological  factor  than  w'as  formerly  believed.  In  142 
cases  of  uterine  carcinoma,  Roger  Williams  found  that  heredity  has 
some  part  in  their  development  in  19.7  per  cent. 

Race. — It  has  been  said  that  the  negress  is  particularly  exempt 
from  carcinoma  of  the  uterus.  Later  observations  tend  to  disprove 
this  view",  indicating  that  she  is  little  less  susceptible  than  the  white 
woman.  Uterine  carcinoma  is  believed  to  be  more  common  in  Europe 
than  elsewhere,  and  is  said  to  be  rare  in  the  tropics. 

Childbearing. — Childbearing  appears  to  have  an  important  relation 
to  the  development  of  carcinoma  of  the  vaginal  portion.  The  author 
has  seen  but  two  carcinomata  of  the  vaginal  portion  in  nulliparae 
whose  cervices  had  never  been  dilated.  The  great  rarity  of  carcinoma 
of  the  cervix  in  nulliparse  speaks  for  the  influence  of  trauma  as  a  factor 
in  the  development  of  cancer.  Carcinoma  of  the  body  of  the  uterus 
is  said  to  be  more  frequent  in  nulliparse. 

There  can  be  no  question  that  the  inflammatory  lesions  of  the  uterus 
(endometritis  and  erosions)  are  not  seldom  the  starting-points  of 
carcinoma,  but  that  scars  in  the  cervix  are  such,  is  justly  questioned. 

Uterine  Fibroids. — While  fibroids  and  carcinoma  are  often  asso- 
ciated in  the  uterus,  it  is  not  probable  that  the  one  is  in  any  way 
dependent  upon  the  other  for  its  existence. 

So  frequently,  however,  is  carcinoma  found  to  develop  in  a  myomatous 
uterus,  that  ice  are  justified  in  regarding  with  suspicion  of  carcinoma  a 
myomatous  uterus  that  begins  to  bleed  after  the  menopause. 

Social  State. — -Carcinoma  of  the  uterus  is  found  more  frequently 
in  the  lower  orders  of  society.  These  classes  are  more  susceptible  to 
and  neglectful  of  infections  and  traumatisms.  On  the  other  hand,  the 
lesion  is  less  frequently  seen  among  the  uncivilized  classes. 

Cohnheim's  theory  of  cell  inclusion  is  not  supported  by  observations 
made  upon  the  carcinomatous  uterus. 

Leopold  concludes  from  a  series  of  experiments  that  pure  cultures 
of  the  blastomycetes  may  be  found  in  fresh  carcinoma  of  the  ovary. 
He  injected  a  pure  culture  into  the  testicle  of  a  rat.  The  animal  died, 
and  on  the  peritoneum  were  found  nodules  in  which  were  similar 
blastomycetic  organisms.  Leopold  infers  that  this  organism  may  be 
the  cause  of  carcinoma  in  man. 

Frequency. — The  frequency  of  carcinoma  of  the  uterus  is  variously 
stated.  Welsh  found  that  in  31,482  cases  of  carcinoma,  29.5  per  cent, 
were  of  the  uterus.  In  point  of  frequency  the  uterus  takes  second  rank 
to  the  stomach  as  a  primary  seat  of  carcinoma.  There  can  be  no  doubt 
but  that  carcinoma  is  on  the  increase,  though  it  is  only  fair  to  admit 
that  the  perfected  means  of  diagnosis  account  in  large  part  for  the 
statistics. 

Roger  Williams  estimated  that  over  10,000  women  suffered  from 
uterine  carcinoma  in  England  and  Wales  in  1898.    He  further  estimated 


634  CARCIXOMA  OF   THE   UTERUS 

that  of  the  deaths  occurring  in  women  over  thirty-five  years  of  age, 
one  in  thirty-five  is  due  to  carcinoma  of  the  uterus. 

Anatomical  Diagnosis. — 1.  Carcinoma  of  the  Vaginal  Portion  of  the 
Cervix. — Carcinoma  of  the  vaginal  portion  of  the  cervix  may  tend  to 
grow  superficially  into  the  vagina,  forming  a  polypoid  or  cauliflower 
growth,  or  it  may  deeply  infiltrate  the  cervix. 

(a)  Cauliflower  Carcinoma. — Cauliflower  carcinoma  of  the  vaginal 
portion  of  the  cervix  is  seen  as  a  sessile  or  pedunculated  gro^^^th,  arising 
from  one  or  both  lips  of  the  cervix.  It  varies  in  size  up  to  the  complete 
filling  of  the  vagina.  The  surface  is  generally  covered  with  a  slimy, 
gangrenous  deposit.  The  whole  mass  bleeds  readily  to  the  touch  and 
is  friable.    The  surface  is  uneven,  nodular,  polypoid,  or  villous. 

(h)  Infiliraiing  Carcinoma  of  the  Vaginal  Portion  of  the  Cervix. — 
Infiltrating  carcinoma  of  the  vaginal  portion  of  the  cervix  appears 
in  the  early  stage  as  an  irregular  thickening  and  hardening  of  the 
cervix.  The  anterior  lip  is  most  often  first  involved.  Cullen  distin- 
guishes three  stages  according  to  the  degree  of  infiltration  and 
disintegration  of  the  cervix.  While  this  classification  is  purely  arbi- 
trary, it  will  be  found  convenient  for  purposes  of  description : 

Stage  1.  The  Stage  of  Infiltration  in  the  Absence  of  Disintegration. 
The  surface  is  hard,  friable,  and  uneven.  The  color  of  the  surface  is 
glistening,  bluish  white.  Cross-sections  of  the  growth  show  a  gray 
or  yellowish-gray  surface,  often  cutting  like  cartilage.  Fibrous  stria- 
tions  are  seen  to  course  through  the  structure,  isolating  nests  of  friable 
homogeneous  tissue,  the  so-called  cancer  nests.  By  squeezing  the 
surface  these  nests  may  be  emptied  of  their  cell  contents,  leaving 
smafl,  shallow  depressions.  Such  nests  are  not  to  be  confused  with 
Xabothian  follicles  filled  with  inspissated  mucus.  The  two  may  be 
found  in  the  same  section.  Unfortunately,  cancer  of  the  vaginal  portion 
is  seldom  observed  at  this  stage,  because  of  the  mild  sjTiiptoms  which 
prevail.  Not  infrequently  there  is  an  entire  absence  of  symptoms. 
While  impossible  to  say  without  an  anatomical  dissection,  it  is  prob- 
able that  the  growth  is  still  confined  to  the  cervix.  Yet  it  must  be 
borne  in  mind  that  not  only  regional  but  general  dissemination  of  the 
carcinoma  may  occur  at  this  stage. 

Stage  2.  The  Stage  of  Moderate  Disintegration. — The  carcinomatous 
tissue  has  partly  disintegrated,  leaving  a  depression  with  irregular, 
hard,  elevated  margins.  The  base  of  the  ulcer  is  uneven,  and  covered 
with  a  stinking  slough  of  a  grayish-yellow  or  gangrenous  character. 
Upon  handling,  the  affected  tissue  bleeds  freely  and  is  friable.  In  this 
stage  the  growth  is  rarely  confined  to  the  cervix.  Ulceration  of  a 
cancerous  growth  does  not  usually  begin  until  the  disease  has  run 
about  half  its  course.  In  a  small  proportion  of  cases  the  growth  never 
ulcerates.     (See  Plate  XXVIII.) 

Stage  3.  The  Stage  of  Complete  Disintegration  of  the  Vaginal  Portion 
of  the  Cervix. — In  the  vault  of  the  vagina  is  a  sloughing,  stinking,  ragged 
crater.  Xo  cervix  is  to  be  seen  or  felt.  The  vaginal  walls  are  invaded 
and  form  the  margins  of  the  crater.    The  paravaginal  connective  tissue, 


PLATE    XXVII 


^ 


.y^ 


Cauliflower  Carcinoma  of  the  Cervix. 


An  irregular  papillary  gro%A/th  oeeupies  both,  lips  of  the  cervix.      It  is  friable 
and  bleeding.    There  is  no  perceptible  infiltration  of  the  cervix. 


PLATE    XXVIII 


Carcinoma  of  the  Cervix,  with  Partial  Disintegration. 

The  growth  is  soft,  friable,  and  bleeding.    The  vagina  and  body  of  the  uterus 

are  invaded. 


ANATOMICAL  DIAGNOSIS 


635 


broad  ligaments,  and  uterosacral  ligaments  are  infiltrated.  The  growth 
is  slow  to  pass  beyond  the  internal  os  into  the  cavity  of  the  uterus,  but 
may  extend  to  the  fundus.  Isolated  cancerous  nodules  may  lie  in 
distant  portions  of  the  vaginal  wall.     Contact  growths  may  develop 


Fig.  419 

i 

■^ 

^^ 

^ 

I 

> 

w% 

^- 

^^1^ 

^ 

-^^ 

/ 

Early  carcinoma  of  the  anterior  cer\-ical  lip.     (Martin.) 


Same  case  as  Fig.  419,  a  part  of  the  cancerous  area  magiii;ii 

(Martin.) 


the  finger-like  projections. 


upon  opposing  surfaces.  The  bladder  is  involved  late  in  the  stage, 
and  the  rectum,  as  a  rule,  still  later.  Only  in  the  late  stage  is  the  peri- 
toneum invaded.  The  iliac  glands  are  the  first  of  the  lymphatics  to  be 
invaded,  but  these  are  usuahy  late  in  being  affected,  and  may  entirely 


636 


CARCINOMA  OF  THE   UTERUS 


escape.    Metastatic  growths  in  distant  parts  of  the  body  are  seldom 
observed. 

2.  Carcinoma  of  the  Cervix. — Carcinoma  of  the  cervix  takes  its  origin 
from  the  epithehum  of  the  cervical  mucosa  confined  within  the  bound- 
aries of  the  external  os  below  and  the  internal  os  above.  The  usual 
site  of  development  is  immediately  above  the  external  os  on  the 
anterior  lip. 

Fig.  421 


Lymphatics  of  uterus  and  upper  third  of  vagina,  and  iliac  and  lumbar  glands.     (Russell.) 


The  carcinomatous  growi:h  may  involve  all  or  a  part  of  the  mucosa. 
It  may  assume  a  nodular  or  cauliflower  appearance,  or  may  infiltrate 
the  underlying  tissue.  The  entire  cervix  may  be  infiltrated  and  will 
eventually  disintegrate,  leaving  a  crater-like  structure  with  a  thin 
shell.  The  lips  of  the  cervix  may  close  in  over  the  growth,  hiding  it 
from  view.  It  is  seldom,  if  ever,  that  the  lips  are  disintegrated,  but  in 
the  late  stages  they  are  infiltrated  and  glazed.  On  cross-section  the 
carcinomatous  mass  is  cartilaginous,  yellowish-white,  and  glistening. 


PLATE    XXIX 


Infiltrating  Carcinoma  of  the  CevviiL. 

The  ^«tire  cervix  is  infiltrated  and  partially  disintegrated.     In  the  cavity 
of  the  uterus  is  a  fungous  growth  (fungous  endometritis). 


ANATOMICAL  DIAGNOSIS 


637 


The  advancing  border  is  irregular  and  blends  into  the  normal  tissue. 
The  body  of  the  uterus  and  vagina  may  be  invaded  either  by  direct 
extension  or  by  metastasis.  The  cervical  canal  may  be  occluded  by 
the  newgrowth  and  be  followed  by  fluid  distention  of  the  uterus 
(pyometra  and  hematometra)  and  tubes  (hydrosalpinx,  hematosalpinx, 
and  pyosalpinx). 


Fig.  422 
15. 


^. 


Advanced  cancer  of  cervix.  Perforation  into  the  urinary  bladder  and  peritoneum.  Medial  section 
of  the  peKis.  1,  perforation  of  cancerous  uterus  into  the  peritoneal  cavity;  2,  intestine;  3,  peritoneum; 
4,  carcinoma  uteri;  .5,  perirectal  inflammatory  infiltration;  6,  perirectal  inflammatory  infiltration;  7, 
coccyx;  8,  rectum;  9,  vagina;  "10,  external  meatus  of  urethra;  11,  internal  meatus  of  urethra;  12,  per- 
foration of  cancerous  uterus  into  bladder;  13,  urinary  bladder;  14,  os  pubis;  15,  perforation  of  cancerous 
uterus  into  peritoneal  cavity.     (Liepmann.) 


Extension  of  Carcinoma  to  Surrounding  Structures. — The  paravaginal 
connective  tissue  is  invaded  comparatively  early.  It  is  unusual  to 
observe  a  case  before  the  broad  ligaments  are  involved,  hence  the 
prognosis  is  always  uncertain. 


638  CARCINOMA  OF  THE  UTERUS 

The  peritoneal  cavity  is  invaded  late.  The  tubes,  ovaries,  bladder, 
and  rectum  are  seldom  attacked.  The  iliacs  are  the  first  of  the  lymph- 
atic glands  to  be  invaded.  ^Metastasis  to  distant  organs  is  said  to 
seldom  occur.  Roger  Williams,  however,  found  that  20  per  cent,  of  his 
cases  had  disseminated  cancerous  foci  in  distant  parts  of  the  body. 
Adenopathy  has  been  known  to  supervene  two  years  before  death, 
though,  as  a  rule,  death  follows  much  more  closely  upon  the  involvement 
of  the  glands.  Winter  found  the  iliac  glands  involved  in  22  per  cent, 
of  cases  of  cancer  of  the  cervix.  He  found  four  cases  of  advanced 
cancer  of  the  cervix  without  involvement  of  these  glands.  Emil  Ries 
has  made  extended  observations  on  the  involvement  of  the  lymphatic 
glands  in  cancer  of  the  cervix.  He  has  shown  that  the  glands  of  the 
pelvis  are  often  cancerous  when  no  larger  than  normal.  Again,  they 
are  sometimes  enlarged  from  hyperplasia,  secondary  to  an  ulcerative 
process  in  the  growth.  Extensive  glandular  involvement  contra-indicates 
all  but  palliative  treatment. 

The  percentage  of  glandular  in^-ol^'ement  in  uterine  carcinoma  is 
difficult  to  determine.  Peisser  estimates  that  50  per  cent,  of  uterine 
cancers  are  accompanied  by  glandular  involvement,  and  Williams 
estimates  72  per  cent.  These  investigations  w^ere  not  verified  by  the 
microscope,  hence  cannot  be  reliable,  for  Ries  has  conclusively  shown 
that  there  may  be  no  enlargement  of  the  glands  in  advanced  cancerous 
invasion  of  the  gland  structure.  Ries  further  states  that  the  size  of 
the  cancer  in  the  cervix  is  in  no  regular  ratio  to  the  size  of  the 
affected  gland.  He  reports  a  case  of  his  own  in  which  the  primary 
cancer  in  the  vaginal  portion  was  not  larger  than  a  thumb  nail,  but 
the  largest  cancerous  gland  M^as  the  size  of  a  pigeon's  egg. 

It  is  of  clinical  interest  to  inquire  whether  the  parametrium  is  always 
involved  prior  to  the  pelvic  lymph  glands.  If  so,  then  failure  to  detect 
infiltration  of  the  parametrium  would  lead  us  to  infer  that  the  pelvic 
glands  are  not  involved,  and  hence  the  Ries-Wertheim  operation  for 
dealing  with  the  pelvic  glands  would  not  be  indicated.  Puppel,  Cullen, 
Pryor,  Kelly,  and  others  are  of  this  opinion,  but  Wertheim  warns  us 
of  the  uncertainty  of  such  conclusions.  The  only  positive  means  of 
demonstrating  the  presence  or  absence  of  cancer  cells  in  the  pelvic 
lymph  glands  is  aft'orded  by  serial  microscopic  sections.  Williams 
points  out  that  in  advanced  cases  of  cervical  cancer  the  supraclavicular 
glands  are  occasionally  enlarged  (Trousier's  sign) .  For  a  more  extended 
discussion  of  the  subject  of  the  lymph  glands  in  uterine  cancer  see 
Gellhorn's  article  in  American  Gyjiecology,. yiovemher,  1902. 

3.  Carcinoma  of  the  Body  of  the  Uterus. — Carcinoma  may  arise  from 
any  part  of  the  mucosa  of  the  uterine  body,  either  as  a  circumscribed 
or  as  a  diffuse  growth.  The  surface  is  never  smooth.  It  begins  as  a 
shaggy  groT\"th  studded  with  delicate  villosities,  which  may  later  enlarge 
and  coalesce  into  polyps  or  form  twig-like  processes  with  numerous 
offshoots.  In  late  and  far-advanced  cases  the  growth  presents  the 
appearance  of  brain  tissue.  The  entire  uterine  cavity  may  be  filled 
with  the  cancerous  growth.     The  musculature  of  the  uterus  is  very 


PLATE    XXX 


Carcinoma  of  Cervix,  Advanced  Stage. 

The  cervix,  is  almost  completely  disintegrated.     The  vaginal 
surface  is  intact. 


CLINICAL  DIAGNOSIS 


639 


slowly  invaded,  and  it  is  for  this  reason  that  cancer  of  the  body  of  the 
uterus  is  regarded  as  relatively  benign. 

On  cross-section  the  invading  carcinomatous  tissue,  with  its  pale, 
homogeneous  and  glistening  appearance,  is  in  contrast  to  the  mus- 
culature. The  advancing  border  is  irregular.  When  the  serous  covering 
of  the  uterus  is  invaded,  small  grayish-yellow  nodules  are  seen  beneath 
the  serosa.    The  growth  is  usually  late  in  sloughing. 


Fig.  423 


rj'  I 


Carcinoma  of  the  fundus. 


A  large  nodule  within  the  uterine  cavity  and  numerous  nodules  beneath 
the  peritoneum.     (Hertzler.) 


Extension  from  the  body  of  the  uterus  is  extremely  slow.  The 
internal  os  is  rarely  trespassed;  the  broad  ligaments  are  not  infiltrated 
until  late.  The  peritoneum  may  be  directly  invaded,  but  this  is  late, 
if  ever.  The  bladder,  rectum,  tubes,  and  ovaries  commonly  escape 
invasion.  Metastasis  to  distant  parts  of  the  body  is  late,  and  may 
never  occur.  Kroemer  believes  that  metastasis  is  more  common  in 
carcinoma  of  the  uterine  body  than  of  any  other  part  of  the  uterus. 

As  to  the  frequency  of  carcinoma  of  the  body  of  the  uterus,  Schatz 
says  that  it  occurs  in  2.5  per  cent.,  while  Schauta  says  that  it  occurs  in 
13.8  per  cent,  of  all  carcinomata  of  the  uterus. 

Clinical  Diagnosis. — A  work  of  this  character  could  do  no  greater 
service  than  to  emphasize  the  importance  of  an  early  diagnosis  in 


640  CARCIXOMA  OF   THE   UTERUS 

carcinoma  of  the  uterus  and  to  point  out  the  methods  of  making 
such  a  diagnosis. 

No  departure  from  the  normal  menstrual  flow  should  he  regarded  as 
trivial  in  advanced  years  of  life.  We  are  not  to  be  content  with  the  sup- 
position that  it  is  a  phenovienon  of  the  change  of  life — too  many  lives 
hare  been  sacrificed  by  such  inferences. 

It  is  the  family  physician,  not  the  specialist,  who  first  sees  these 
cases,  and  it  is  to  him  we  must  look  for  the  early  recognition  of  the 
danger,  if  not  for  a  positive  diagnosis.  The  practitioner  must  be  firm 
in  his  demand  for  a  local  examination.  Ignorance,  sloth,  prejudice, 
and  false  modesty  are  to  be  discountenanced.  When  the  physician, 
after  a  searching  examination  into  the  cause  of  the  hemorrhage,  fails 
to  satisfy  himself,  he  should  appeal  to  the  specialist,  whose  services 
at  this  time  are  of  greater  value  than  in  the  treatment  of  the  case,  for 
the  reason  that  it  takes  greater  skill  to  make  a  diagnosis  in  these 
doubtful  cases  than  it  does  to  remove  the  uterus  after  the  diagnosis 
is  made.  Since  the  early  recognition  of  carcinoma  of  the  uterus  rests 
upon  the  microscopic  examination  of  scrapings  and  excised  pieces  of  the 
suspected  portion,  it  is  self-evident  that  only  those  especially  trained 
in  the  work  are  competent  to  make  such  a  diagnosis. 

^Ye  will  here  discuss  acute  and  chronic  cancers. 

Acute  Cancers. — Acute  cancers,  including  those  which  run  their 
course  within  a  year,  are  frequently  met  with.  Kiwisch  observed  a 
case  which  ran  its  entire  course  in  five  weeks,  and  ]\Iartin's  case  died 
within  nine  weeks  of  its  inception.  Associated  with  the  gro'^'th  in  the 
uterus  are  febrile  symptoms  and  general  dissemination. 

Chronic  Cancers. — Chronic  cancers,  including  those  which  run  their 
course  in  three  years  or  more,  are  rare.  Barker's  case  continued  eleven 
years.  Carcinoma  of  the  uterine  body  is  slow  in  its  course  as  compared 
with  carcinoma  of  the  cervix  or  vaginal  portion.  Odebrecht  obtained 
a  permanent  recovery  by  operating  on  a  cancer  of  the  body  of  the 
uterus  five  years  and  four  months  after  it  was  kno\\Ti  to  exist.  Symp- 
toms in  the  early  stage,  while  there  is  yet  time  to  interfere,  are  at  best 
only  suggestive  of  the  lesion  and  may  be  wholly  wanting  until  the 
disease  has  reached  the  inoperable  stage.  Schauta  found  that  13  per 
cent,  of  the  cases  which  he  examined  within  four  weeks  of  the  beginning 
of  symptoms  were  inoperable. 

Hemorrhage. — Hemorrhage  is  usually  the  first  of  the  s\Tnptoms  to 
appear.  It  is  at  first  excited  by  some  physical  exertion,  such  as  strain- 
ing at  stool,  lifting  burdens,  and  sexual  intercourse.  All  departures 
from  the  normal  menstrual  flow,  or  all  losses  of  blood  not  in  relation 
to  the  menstrual  period,  call  for  a  careful  examination.  The  older  the 
individual  the  greater  the  probability  of  carcinoma.  In  carcinoma  the 
loss  of  blood  is  usually  slight  at  first;  more  rarely  does  it  begin  with  a 
profuse  flow.  A  watery  discharge  may  precede  the  flow  of  blood  weeks 
and  months,  and  is  highly  suggestive  of  carcinoma.  The  patient  becomes 
anemic,  and  her  strength  fails  as  a  result  of  the  hemorrhage.  In  the 
late  stage,  when  there  is  great  enfeeblement,  hemorrhage  becomes 
less  profuse,  and  may  almost  cease. 


PLATE    XXXI 


■3aoa^ 


Cancer  of  the  Vaginal  Portion  of  the  Cervix.     (Third  stage.) 

The  entire  cervix  is  disintegrate<i.  In  the  vault  of  the  vagina  is 
an  irregular,  friable,  and  bleeding  crater.  The  walls  of  the  vagina 
are  infiltrated. 


CLINICAL  DIAGNOSIS  641 

Leucorrhea. — Leucorrhea  is  almost  invariably  present,  at  first  in 
the  form  of  a  watery,  odoriess  discharge,  later  as  a  thicker  white  or 
yellowish  fluid,  and,  finally,  as  a  stinking,  dirty,  bloody  discharge. 
Such  a  discharge  can  only  be  regarded  with  suspicion;  it  is  in  no  sense 
pathognomonic,  and  may  be  late  in  making  its  appearance.  Sloughing 
fibroids,  decomposing  placental  tissue,  and  senile  endometritis  may 
cause  a  similar  discharge.  As  in  hemorrhage,  so  with^uch  a  leucorrhea, 
a  careful  examination  is  imperative. 

Pain. — Pain  is  seldom  an  early  manifestation  of  carcinoma  of  the 
uterus,  and  is  less  reliable  as  a  guide  to  diagnosis  than  is  hemorrhage 
or  leucorrhea.  Not  infrequently  the  growth  is  far  advanced  before 
pain  is  experienced.  In  such  cases  the  pain  begins  when  the  gro^^i:h 
has  extended  beyond  the  uterus.  Pain  and  hemorrhage  are  often  in 
inverse  proportion.  The  pain  is  aggravated  by  the  congestion,  and 
when  the  flow  of  blood  is  considerable  the  congestion  is  relieved,  and 
this  in  turn  lessens  the  pain.  Roger  Williams  found  little  or  no  pain 
in  one-seventh  of  his  cases.  ^Yhen  present  the  pain  of  uterine  cancer 
is  generally  referred  to  the  groin,  thighs,  sacral  or  hypogastric  regions. 
In  the  early  stages  the  pain  is  of  a  dull  aching  and  dragging  character. 
Later,  as  the  adjacent  structures  are  involved,  the  pain  may  be  severe 
and   constant. 

Miscellaneous  Symptoms. — Miscellaneous  symptoms  arise  from  exten- 
sion to  the  surrounding  structures.  The  bowels  become  constipated, 
and  defecation  is  painful  from  the  pressure  of  the  growth.  As  the 
rectum  is  invaded  a  mucous  or  mucohemorrhagic  discharge  comes 
from  the  rectum;  finally,  a  rectovaginal  fistula  develops.  Invasion 
of  the  bladder  causes  frequent  urination,  irritability  of  the  bladder, 
bloody  urine,  and,  finally,  a  vesicovaginal  fistula. 

^Mien  the  cellular  tissue  of  the  pelvis  is  involved  there  may  be  pain 
referred  to  the  groin,  thighs,  and  legs.  Edema  of  the  legs,  often  of 
one  side,  may  result  from  an  involvement  of  the  veins  and  lymphatics 
of  the  pelvis.  In  almost  every  case  of  advanced  carcinoma  of  the 
uterus  the  kidneys  are  involved  and  uremic  s\Tnptoms  may  be  manifest. 

Cachexia. — Cachexia  develops  in  the  advanced  stage,  though  it 
may  be  surprisingly  late  in  making  its  appearance.  The  above  symp- 
toms are  responsible  for  the  cachexia. 

Uterine  cancer  patients  seldom  take  to  their  bed  until  at  least  half- 
of  the  course  of  the  disease  is  run.  Occasionally  the  general  health 
fails  from  the  beginning  of  the  lesion,  and  on  the  other  hand  death  has 
been  known  to  result  from  the  disease  without  marked  general  symp- 
toms. A  gradually  increasing  asthenia  usually  brings  the  case  to  a 
fatal  termination. 

I.  Diagnosis  of  Cancer  of  the  Vaginal  Portion  of  the  Cervix. — The  diag- 
nosis of  carcinoma  of  the  vaginal  portion  of  the  cervix  can  be  made 
with  greater  ease  and  certainty  than  in  any  other  portion  of  the  uterus, 
because  of  the  greater  accessibility  to  touch  and  sight.  In  the  infiltrat- 
ing form,  with  an  overlying  covering  of  mucous  membrane,  the  diagnosis 
is  difficult  without  the  aid  of  the  microscope. 
41 


642 


CARCINOMA  OF  THE  UTERUS 


The  broadening  of  the  cervix,  the  irregular  nodular  surface,  the 
cartilaginous  consistency,  and  the  glistening,  bluish  color  are  not 
sufficiently  characteristic.  The  friability  and  tendency  to  bleed  when 
grasped  by  a  tenaculum  or  when  the  finger  nail  is  gouged  into  it, 
are  regarded  by  many  gynecologists  as  characteristic  of  cancer,  and 
altogether  reliable  in  making  a  diagnosis. 


Fig.  424 


Priman-  carcinoma  of  the  cerA-ix; 


.i^j.  with  a  large  submucous  fibroid. 


"\^Tlile  much  reliance  can  be  placed  on  these  signs,  the  microscopic 
examination  of  an  excised  piece  of  the  suspected  portion  must  be 
regarded  as  the  conclusive  test,  without  which  a  positive  diagnosis 
is  often  impossible.  "^Mien  ulceration  is  present  the  diagnosis  is  made 
with  greater  ease.  The  hard,  glistening,  irregularly  elevated  border, 
together  with  the  friability  and  tendency  to  bleed  when  handled,  leave 
little  doubt  as  to  the  carcinomatous  nature.  There  is  then  little  need 
for  the  microscope  to  confirm  the  diagnosis. 

A  cauliflower  gro-uth  is  more  readily  recognized  as  malignant  than 
the  infiltrating  form,  yet  papillary  erosion  must  be  excluded,  and  to 
make  a  careful  differentiation,  the  microscope  will  often  be  found 
indispensable.  The  greater  the  clinical  experience  of  the  examiner, 
the  larger  will  be  the  percentage  of  cases  in  which  the  diagnosis  can 


CLINICAL  DIAGNOSIS  643 

be  made  from  the  clinical  signs  and  symptoms.  But  there  will  remain 
a  certain  number  in  which  the  diagnosis  can  only  be  made  by  a  micro- 
scopic examination  of  an  excised  piece  of  the  suspected  portion.  (See 
Microscopic  Diagnosis,  page  133.) 

II.  Diagnosis  of  Carcinoma  of  the  Cervix. — The  diagnosis  of  carcinoma 
of  the  cervix  is  rarely  made  early,  because  the  growth  is  not  accessible  to 
the  sense  of  touch  or  sight,  hidden  as  it  is  above  the  external  os.  Indeed, 
the  growth  may  go  on  to  an  advanced  stage,  destroying  the  mucous 
membrane  and  underlying  connective  tissue,  and  yet  be  unsuspected. 
When  the  destruction  of  tissue  is  seen  through  a  vaginal  speculum 
the  diagnosis  is  not  difficult,  but  this  is  not  possible  in  the  early  stage 
when  a  radical  cure  is  reasonably  assured. 

When  the  cervix  is  artificially  dilated  bleeding  is  profuse  and  tear- 
ing can  scarcely  be  avoided.  The  finger  or  curet  gouges  out  friable 
masses.  The  friability  and  bleeding  of  the  tissue  are  so  characteristic 
as  to  leave  little  doubt  of  the  carcinomatous  nature  of  the  growth. 
It  is  scarcely  necessary  to  resort  to  the  microscope  to  confirm  the 
diagnosis. 

III.  Diagnosis  of  Carcinoma  of  the  Body  of  the  Uterus. — The  diagnosis 
of  carcinoma  of  the  body  of  the  uterus  presents  the  greatest  possible 
difficulties.  There  are  no  symptoms  that  may  be  regarded  as  pathog- 
nomonic; the  lesion  is  beyond  the  reach  of  the  examining  finger,  and 
cannot  be  brought  under  inspection.  The  general  nutrition  of  the 
individual  bears  little  relation  to  the  stage  of  the  growth.  She  may 
retain  her  weight  into  the  last  stage. 

Hemorrhage,  a  foul-smelling  discharge,  and  pain  usually  occur  in  the 
order  named,  but  it  is  possible  for  one  or  all  of  these  symptoms  to  be 
absent,  and  more  often  there  is  nothing  in  the  symptoms  to  suggest 
anything  more  serious  than  endometritis. 

//  every  menstrual  irregularity  occurring  late  in  life  a7id  every  inter- 
menstrual or  'postmenoyausal  hemorrhage  were  regarded  with  suspicion  of 
carcinoma,  and  a  thorough  search  made  into  the  cause,  few  carcinomata 
of  the  uterus  would  long  go  unrecognized. 

It  is  usual  for  the  menstrual  periods  to  have  been  regular,  for  the 
menopause  to  have  passed  in  the  ordinary  way,  and  for  some  months 
or  years  to  have  intervened  before  the  appearance  of  hemorrhage. 
The  author  has  seen  a  case  in  which  the  menopause  had  been  passed 
forty-eight  years  when  hemorrhage  returned.  Even  with  this  long 
interval  the  patient  and  friends  thought  the  loss  of  blood  was  due  to 
a  return  of  the  menses.  Their  suspicions  were  confirmed  to  their  entire 
satisfaction  when  the  flow  of  blood  ceased  in  a  few  days  and  returned 
in  four  weeks.  This  disposition  on  the  part  of  the  patient  to  believe 
that  postmenopausal  hemorrhages  are  the  return  of  the  menses  is  too 
frequently  responsible  for  the  high  rate  of  mortality  in  carcinoma  of 
the  uterus. 

There  is  little  difference  in  the  subjective  signs  of  carcinoma  of  the 
body  of  the  uterus  and  those  of  the  cervix  or  vaginal  portion.  The 
constitutional  effects  appear  much  slower.     It  is  impossible  to  say 


644  CARCINOMA  OF  THE   UTERUS 

when  the  growth  begins.  We  commonly  date  the  appearance  of  the 
carcinoma  from  the  time  of  the  onset  of  the  watery  discharge  or  hemor- 
rhage, but  it  is  to  be  borne  in  mind  that  these  symptoms  may  be  due 
to  endometritis  which  has  not  as  yet  developed  into  a  malignant  growth ; 
and,  on  the  other  hand,  these  symptoms  may  follow  weeks  and  months 
after  the  beginning  of  malignant  degeneration.  The  slow  growth  of 
carcinoma  of  the  body  of  the  uterus  is  illustrated  by  a  case  of  Cullen's, 
in  which  a  hysterectomy  was  performed  two  years  after  the  onset  of 
symptoms,  and  the  disease  was  seen  to  have  made  little  progress. 

In  a  case  operated  upon  by  Dr.  J.  Clarence  Webster  the  symptoms 
began  three  years  previous  to  the  operation.  The  growth  was  still 
apparently  confined  to  the  body  of  the  uterus. 

We  now  see  that  the  subjective  signs  cannot  be  relied  upon  in  making 
a  diagnosis,  and  that  we  must  depend  largely  upon  physical  signs. 

Bimanual  palpation  of  the  uterine  body  shows  a  slight  uniform  enlarge- 
ment, together  with  some  degree  of  softening.  In  the  early  stage  the 
size  and  consistency  of  the  uterus  are  not  changed.  In  the  advanced 
stage,  when  the  growth  has  extended  to  the  serosa,  small  nodules 
may  be  palpated  on  the  outer  surface  of  the  uterus,  giving  the  impression 
of  small  subperitoneal  fibroids.     (See  Fig.  386.) 

Exploration  of  the  uterine  cavity  is  essential  to  a  positive  diagnosis. 
This  is  accomplished  by  the  examining  finger,  the  sound,  or  the  curet. 

After  dilating  the  cervix  sufficiently  to  admit  the  index  finger,  the 
entire  surface  of  the  endometrium  can  be  explored.  Soft,  friable, 
and  irregular  elevations  upon  the  surface  are  located,  and  may  be 
scraped  off  by  the  finger  for  a  microscopic  examination.  It  is  possible 
in  the  early  stage  for  a  growth  that  is  not  distinctly  raised  above  the 
surface  to  escape  detection  by  the  examining  finger. 

The  uterine  sound  will  detect  the  irregularities  upon  the  surface 
of  the  endometrium  with  less  certainty,  and  will  afford  much  less 
intelligent  information  regarding  the  consistency  and  extent  of  the 
growth.  In  carcinoma  the  sound  will  sink  into  the  soft  growth  and 
cause  considerable  bleeding. 

An  exploratory  curettage,  followed  by  a  microscopic  examination 
of  the  scrapings,  will  supply  an  absolute  means  of  making  a  diagnosis, 
and  should  be  made  in  every  case,  no  matter  what  the  other  findings 
may  be. 

Microscopic  Diagnosis. — An  early  diagnosis  of  carcinoma  of  the 
uterus  is  seldom  made  from  clinical  manifestations  or  from  the  naked- 
eye  appearances  of  the  growth.  The  only  positive  means  of  making  an 
early  diagnosis  is  by  a  microscopic  examination  of  excised  pieces  and 
of  scrapings  removed  by  the  curet. 

I.  Carcinoma  of  the  Vaginal  Portion  of  the  Cervix. — In  advanced  cases 
when  there  is  ulceration  of  the  cervix  and  when  the  vagina  and  para- 
metrium are  infiltrated,  a  microscopic  examination  is  seldom  necessary. 
In  the  early  stage  no  characteristic  features  may  be  observed  by  the 
naked  eye,  and  it  is  in  such  cases  that  the  microscope  is  indispensable. 
The  technic  of  excising  a  piece  of  the  cervix  for  a  microscopic  exami- 


MICROSCOPIC  EXAMINATION 


645 


nation  is  to  sterilize  the  vagina  as  for  a  vaginal  operation;  grasp  the 
cervix  with  a  tenaculum,  and  with  knife  or  scissors  remove  a  wedge, 
including  part  of  the  suspected  portion  and  part  of  the  apparently 


Fig.  425 


Papillary  erosion  of  cer\'ix  undergoing  malignant  degeneratic 
Fig.  426 


"5  * 


^.^ 


Adenocarcinoma  of  the  cervix. 
Fig.  427 


_,    ^^)UL//^ 


■•-•^r/  cy?5  y'"""\  ^i'X  ''-'-'     '  ■ 


kg!0^' 


.0^>&»^  C...y^C 


■^•^  x,^ 


Papillarjr  carcinoma  of  the  cervix. 


healthy  tissue.  Following  the  incision  catgut  sutures  are  used  to  close 
the  wound,  and  the  vagina  is  packed  with  gauze.  An  anesthetic  is 
desirable,  though  not  absolutely  necessary. 


646 


CARCINOMA  OF  THE   UTERUS 


The  microscopic  appearance  of  an  infiltrating  sqnamous-cell  carci- 
noma of  the  cervix  is  that  of.  many  layers  of  flat  epithelium,  varying 


Fig.  428 


^'^^^M 


Squamous-cell  carcinoma  of  the  cervix. 
Fig.  429 


■®  © 


VVf-^^ 


Proliferation  of  the  superficial  columnar  epithelium.     The  new-formed  epithelium  is  seen  to  invade 
the  connective  tissue  in  the  act  of  forming  a  malignant  gland. 


Fig.  430 


-.'■^^li 


@, 


^^./l-^s^-= 


.  ^aV-^<V  ^X  ^ 


^■5:5^:*-x 


'^^^^^ 


Proliferation  of  the  superficial  columnar  epithelium.  The  new-formed  epithelium  extends  outward, 
forming  papillarj-  projections  into  which  connective-tissue  fibers  grow  to  form  a  framework.  There 
is  no  invasion  of  the  connective  tissue.  The  figure  represents  the  beginning  of  a  malignant  papillary 
growth. 


MICROSCOPIC  DIAGNOSIS 


647 


greatly  in  size  and  in  form  from  the  normal  epithelium  of  the  vaginal 
portion.  The  cells  may  be  no  larger  than  a  leucocyte,  or  considerably 
larger  than  normal.  The  nuclei  are  relatively  large,  and  often  segmented. 
They  take  a  deep  stain  and  show  many  karyokinetic  figures.  A  variable 
amount  of  protoplasm  surrounds  the  nuclei.  The  cells,  grouped  in 
irregularly  projecting  columns,  invade  the  underlying  tissues  and 
may  finally  wholly  replace  the  cervix.  About  the  margins  of  these 
projecting  columns  is  a  round-cell  infiltration  of  the  connective-tissue 
stroma.  Cross-sections  of  these  epithelial  columns  appear  as  "cancer 
nests"  (Fig.  432),  and  in  them  "cancer  pearls"  (Fig.  431)  are  usually 
found. 

Fig.  431 


Cancer  pearl  composed  of  concentric  layers  of  hornified  epitlielium. 
Fig.  432 


Cancer  nest  with  a  necrotic  centre. 


i  The  microscopic  diagnosis  of  a  cauliflower  carcinoma  of  the  vaginal 
portion  of  the  cervix  is  to  be  made  from  an  excised  piece  of  the  suspected 
portion.  The  sections  must  be  made  perpendicular  to  the  cervix,  in 
order  to  observe  the  epithelial  invasion  of  the  latter.  The  finger-like 
projections  which  aggregate  to  make  a  cauliflower  growth  are  composed 
of  a  framework  of  connective  tissue  which  contains  a  central  blood- 
vessel, many  round  cells,  and  a  variable  number  of  invading  epithelial 


648  CARCINOMA  OF  THE   UTERUS 

cells  (Fig.  -133).  The  surface  is  covered  with  many  layers  of  squamous 
epithelium  not  unlike  those  described  above  in  the  infiltrating  form  of 
carcinoma.  The  epithelium  invades  the  underlying  connective  tissue 
of  the  cervix,  and  it  is  this  feature  that  gives  the  malignant  character 
to  the  growth.  Cancer  nests  may  show  various  stages  of  degeneration. 
Giant  cells  are  relatively  abundant.  Hyaline  degeneration  of  the  cancer 
cells  is  common,  and  the  nuclei  may  be  fragmented. 

Fig.  433 


-i.i 


■'■<  '^^^  ■ 


T^    .Si'*    •  1--  - 


i 


A  finger-like  projection  of  a  squamous-cell  carcinoma  of  the  cer\is. 


Erosion  carcinoma  is  a  term  implying  malignant  degeneration  of  an 
erosion  of  the  cervix.  The  malignant  changes  commonly  begin^on  the 
surface  of  the  erosion,  less  frequently  from  the  glands  and  follicles.  In 
this  way  it  is  possible  to  have  a  cylindrical-cell  carcinoma  in  the  vaginal 
portion  of  the  cervix. 

II.  Carcinoma  of  the  Cervix. — Two  general  histological  forms  of 
carcinoma  of  the  cervix  are  recognized,  alveolar  and  glandular.    These 


SQUAMOUS-CELL  CARCINOMA  OF  BODY  OF   UTERUS       649 

forms  take  their  origin  from  the  surface  epithelium  or  from  preexisting 
glands.  In  either  form  the  wall  of  the  cervix  may  be  deeply  infiltrated 
and  the  cervical  canal  filled.  Ruge  and  Veit  describe  a  budding  process 
in  the  development  of  malignant  gland  formations.  Groups  of  epithelial 
cells  bud  from  either  side  of  the  lumen  of  a  gland  and  unite  to  form  a 
bridge  across  the  gland.  Eventually  the  lumen  of  the  gland  may  be 
filled  with  epithelial  cells.  In  no  essential  way  does  carcinoma  of  the 
cervix  differ  from  carcinoma  of  the  body  of  the  uterus. 

III.  Carcinoma  of  the  Body  of  the  Uterus. — In  carcinoma  of  the  body 
of  the  uterus  we  see  a  great  variety  of  histological  forms.  In  general 
there  are  found  the  adenocarcinoma  and  the  alveolar,  very  rarely  the 
squamous-cell  carcinoma. 

Adenocarcinoma  may  assume  a  type  sometimes  spoken  of  as  malig- 
nant adenoma — i.  e.,  a  glandular  gro^^i:h  in  which  the  glands  are  greatly 
increased  in  number  and  invade  the  musculature.  There  is  but  a  single 
layer  of  epithelium,  and  the  glands  are  very  irregular  in  outline  and 
often  increased  in  size.  It  is  difficult  to  differentiate  an  early  malignant 
adenoma  from  an  advanced  type  of  hyperplastic  glandular  endometritis, 
or  what  is  sometimes  called  a  benign  adenoma.  Gebhard  describes 
two  varieties  of  malignant  adenoma — the  everted  form,  in  which  the 
gland  irregularities  project  outward  from  the  lumen,  and  the  inverted 
form,  in  which  the  irregularities  project  into  the  lumen  of  the  gland. 
The  two  forms  are  often  combined. 

When,  in  addition  to  irregularity  in  outline  and  great  increase  in  the 
number  of  the  glands,  the  epithelium  proliferates  to  form  two  or  more 
layers  and  the  basement  membrane  is  broken  through,  we  have  formed 
the  adenocarcinoma. 

Alveolar  carcinoma  may  form  by  the  complete  filling  up  of  the  gland 
lumen  in  the  advanced  stage  of  adenocarcinoma,  or  the  surface  epithe- 
lium may  invade  the  underlying  tissue,  giving  rise  to  the  formation 
of  "cancer  nests." 

Squamous-ceU  Carcinoma  of  the  Body  of  the  Uterus. — There  are 
but  few  authentic  cases  of  squamous-cell  carcinoma  of  the  body  of  the 
uterus  reported.  To  deny  the  possible  existence  of  such  gro\\'ths,  as  does 
Cullen  in  his  admirable  work  on  Cancer  of  the  Uterus,  is  unwarranted 
from  a  study  of  the  recorded  cases.  That  multiple  layers  of  squamous 
epithelium  of  a  perfectly  benign  character  are  found  has  been  well 
established  by  Veit,  Gebhard,  Ries,  and  others.  It  is  only  reasonable 
to  infer  that  such  benign  metamorphosis  may  in  turn  become  trans- 
formed into  squamous-cell  carcinomata. 

Zeller,  in  1885,  observed  in  the  scrapings  of  all  forms  of  endometritis, 
isolated  areas  of  stratified  squamous  epithelium  showing  none  of  the 
characters  of  a  malignant  growi:h.  Gebhard  and  Menge  made  similar 
observations  in  gonorrheal  endometritis.  Werth  examined  the  mucosa 
ten  days  after  curettage,  finding  islets  of  squamous  epithelium  in  the 
mouths  of  glands.  Gottschalk  and  Winkler  record  similar  observations 
in  the  endometrium  of  pregnancy  in  the  fifth  and  third  months  respec- 
tively.    Opitz  and  Gebhard  found  small  papillary  elevations  in  the 


650  CARCINOMA  OF  THE   UTERUS 

decidua,  composed  of  three  or  four  layers  of  squamous  cells.  Meier 
and  Friedlander  made  observations  on  the  uteri  of  fetuses  and  infants, 
in  which  they  demonstrated  isolated  patches  of  squamous  epithelium, 
four  to  six  layers  in  thickness,  the  lowermost  layer  being  cylindrical, 
the  uppermost  layer  hornified,  and  the  intermediate  layer  cubical  in 
form.  Huegge  reports  two  cases,  forty-four  and  forty-nine  years  of 
age,  in  which  curettage  was  performed  for  the  control  of  hemorrhage. 
Transformation  and  proliferation  of  the  epithelium  into  stratified 
squamous  epithelium  was  found  in  both  specimens. 

Fig.  434 


".■^  *r 


■  (■■ 

f 

■  V"^- 

J^-^ 

%. 

SSi^'^-.'7s>,r 

Combination  of  squamous-cell  carcinoma  and  adenocarcinoma  of  the  corpus  uteri. 

In  none  of  the  above  recorded  cases  was  there  evidence  of  malig- 
nancy. The  benign  metamorphosis  occurred  from  the  ninth  month 
of  fetal  life  to  the  forty-ninth  year.  Bebkiser,  Hofmeier,  and  Gebhard 
each  described  a  case  in  which  the  benign  stratified  epithelium  became 
transformed  into  a  malignant  squamous  epithelial  growth.  Kaufman 
curetted  the  uterus  of  a  woman,  aged  sixty-four. years,  who  had  suffered 
from  uterine  hemorrhage  six  years.  In  the  scrapings  were  typical 
fields  of  adenocarcinoma,  together  with  nests  of  squamous-cell  carci- 
noma containing  cancer  pearls. 

It  is  probable,  as  Winter  says,  that  these  growths  never  arise  directly 
from  cylindrical  epithelium.  It  is  more  likely  that  through  mechanical, 
chemical,  and  mytotic  influences  the  cylindrical  cells  proliferate,  become 
flattened,  and  subsequently  undergo  malignant  transformation. 

Fig.  434  is  drawn  from  a  specimen  removed  by  Dr.  J.  Clarence 


DIFFERENTIAL  DIAGNOSIS  651 

Webster  in  the  Presbyterian  Hospital  of  Chicago.  In  the  specimen  is 
an  interstitial  fibroid  of  the  uterine  body  lying  directly  posterior  to  a 
cauliflower  growth  of  the  endometrium.  This  endometrial  gro^\-th  is 
about  two  inches  in  diameter,  is  soft  and  friable,  and  shows  no  visible 
degenerative  changes.  The  remainder  of  the  endometrium  is  appar- 
ently normal.  Microscopic  sections  show  an  adenocarcinoma.  T}^ical 
in  form  and  intimately  associated  with  malignant  glands  are  areas  of 
apparently  squamous-cell  carcinoma.  In  the  field  will  be  seen  glands 
partially  filled  with  flat  epithelium,  and  cells  showing  transition  stages 
from  the  cylindrical  to  the  flat  cells.  No  cancer  pearls  are  found.  After 
a  thorough  search  throughout  the  endometrium,  not  involved  in  the 
cauliflower  growth,  no  evident  metamorphosis  of  the  surface  epithelium 
could  be  found.  It  is  probable  that  the  existence  of  the  flat  epithelium 
may  be  accounted  for  by  the  presence  of  the  encroaching  fibroid — a 
result  of  pressure. 

I.  Differential  Diagnosis. — Vaginal  Portion  of  the  Cervix. — Carci- 
noma of  the  vaginal  portion  of  the  cervix  is  to  be  differentiated  from 
eversion  of  the  mucous  membrane,  erosions  of  the  cervix,  decubitus, 
tuberculous  and  syphilitic  ulcers,  follicular  degeneration  of  the  cervix, 
metritis  coli,  and  sarcoma. 

Eversion  of  the  mucous  membrane  of  the  cervix  follows  laceration  of 
the  cervix.  Viewing  the  cervix  through  a  speculum,  the  eversion  is 
often  exaggerated  by  the  traction  made  by  the  speculum  upon  the  cervix. 
Grasping  the  two  everted  lips  of  the  cervix  with  tenacula  and  bringing 
them  together,  the  everted  mucous  membrane  is  rolled  in,  leaving  a 
normal  appearing  cervix.  The  suspected  portion  is  not  friable  and  does 
not  bleed  freely  when  handled.  Finally,  if  a  section  of  the  everted 
mucosa  is  examined  under  the  miscrocope  it  is  seen  to  be  either  normal 
or  hypertrophied.  There  is  no  evidence  of  an  epithelial  invasion  of 
the  underlying  tissue. 

Erosion  of  the  cervix  (mucous  patch)  may  be  confused  with  carcinoma 
when  having  a  papillary  surface  or  when  deeply  indurated.  Erosions 
seldom  bleed  so  freely  as  does  carcinoma,  and  the  tissue  is  less  friable. 
When  doubt  exists  a  microscopic  examination  of  an  excised  piece  of 
the  suspected  portion  will  confirm  the  diagnosis.  Xo  epithelial  invasion 
will  be  found  beneath  the  basement  membrane. 

Decubitus  ulcers  of  the  cervix,  due  to  pressure  from  ill-fitting  pessaries 
and  friction  of  the  cervix  and  thighs  in  prolapsus  uteri,  are  recognized 
by  their  punched-out  appearance,  the  absence  of  hard,  elevated  margins, 
the  granular  bed  in  the  absence  of  induration,  and,  finally,  by  a  micro- 
scopic examination  of  excised  pieces  of  the  ulcer  in  which  there  is 
found  no  epithelial  invasion  of  the  underlying  structures.  On  removal 
of  the  pessary  and  replacing  the  prolapsed  uterus,  there  is  a  tendency 
to  healing  which  is  never  present  in  carcinomatous  ulcers. 

Tuberculous  ulcers  of  the  cervix  are  rare  as  compared  with  carcinoma. 
A  tuberculous  family  history,  the  presence  of  tuberculosis  elsewhere 
in  the  body,  and  particularly  in  the  upper  genital  tract,  will  suggest 
the  possible  nature  of  the  lesion.    The  tuberculous  ulcer  has  a  ragged, 


652  CARCINOMA  OF  THE  UTERUS 

undermined  margin  in  contrast  to  the  hard,  elevated  margin  of  a  carci- 
nomatous ulcer.  The  bed  of  the  ulcer  is  not  indurated  as  in  carcinoma, 
and  may  be  studded  with  tubercles  and  covered  with  a  yellowish  secre- 
tion. Miliary  tubercles  may  surround  the  margins  of  the  ulcer.  There 
is  not  the  tendency  to  bleed  when  handled,  nor  is  the  tissue  so  friable 
as  in  carcinoma.  Finally,  a  microscopic  examination  of  excised  pieces 
will  reveal  the  tubercles,  giant  cells,  and  possibly  the  tubercle  bacillus, 
and  there  will  be  an  absence  of  deep  invasion  of  the  epithelium.  There 
is  a  tendency  to  heal  by  cicatrization  not  seen  in  cancerous  ulcers. 
Beyea  speaks  of  ulcerative,  miliary,  papillary,  and  hyperplastic  tuber- 
culous endocervicitis.  Papillary  tuberculous  endocervicitis,  according  to 
Beyea,  is  distinguished  from  a  cauliflower  carcinoma  by  the  following: 

1.  Not  bleeding  so  freely  or  so  early  as  carcinoma. 

2.  More  elastic  and  velvety  and  less  friable  than  is  carcinoma. 

3.  Commonly  occurring  during  the  period  of  sexual  maturity  while 
carcinoma  occurs  later. 

4.  Great  variations  in  history  and  in  duration. 

5.  Microscopic  examination  showing  lesions  typical  of  tuberculosis 
and  the  absence  of  epithelial  invasion. 

A  syphilitic  ulcer  is  single,  shallow,  and  deeply  indurated;  the  bed  of 
the  ulcer  may  be  covered  with  a  grayish-yellow  deposit,  and  the  margins 
are  not  elevated  but  are  described  as  serpiginous.  The  discharge  is 
slight.  There  is  a  tendency  to  heal  by  cicatrization.  Multiple  ulcerated 
papules  may  be  present.  Under  the  microscope  there  is  noted  an 
absence  of  epithelial  invasion  of  the  cervix.  Secondary  syphilides 
assume  the  form  of  erosions  and  condylomata.  There  is  usually  an 
absence  of  induration  and  the  lesions  are  multiple.  These  character- 
istics, together  with  the  history  and  the  presence  of  syphilitic  lesions 
elsew^here  in  the  body,  should  render  the  diagnosis  possible. 

Tertiary  syphilitic  affections  of  the  portio  are  found  in  the  form 
of  gummata,  more  or  less  diffuse  fibrosis,  and  ulcers.  The  ulcers  may 
appear  gangrenous  and  lead  to  confusion  in  the  diagnosis.  Nothing 
short  of  the  Wassermann  test,  of  antisyphilitic  treatment  and  a  micro- 
scopic section  of  the  ulcer  can  determine  the  true  nature  of  the  lesion. 

Follicular  degeneration  of  the  cervix,  or  what  is  commonly  known 
as  a  follicular  erosion,  is  described  on  page  417.  The  cervix  may 
be  much  enlarged,  irregular,  and  nodular.  Cutting  into  the  irregular 
elevations,  inspissated  mucus  escapes.  The  suspected  tissue  is  tough, 
not  friable  as  in  carcinoma,  and  does  not  bleed  when  handled.  The 
microscope  shows  distended  glands,  with  an  intact,  overlying  mucosa, 
not  invading  the  underlying  connective  tissue. 

An  interstitial  fibroid  of  the  cervix  is  commonly  associated  with  similar 
growths  in  the  body  of  the  uterus.  The  tumor  is  firm,  sharply  circum- 
scribed, and  shows  no  tendency  to  friability  and  bleeding.  On  cross- 
section  and  under  the  microscope  a  fibrous  or  fibromuscular  structure 
is  seen. 

Metritis  coli  is  a  chronic  inflammation  of  the  cervix  causing  such 
thickening  and  hardening  of  the  tissue  as  to  suggest  malignant  infil- 


DIFFERENTIAL  DIAGNOSIS  653 

tration.  The  enlargement  is  uniform  as  contrasted  with  the  irregular 
growth  of  the  carcinomatous  cervix ;  there  is  an  absence  of  the  cartilagi- 
nous firmness  of  the  cervix  of  the  first  stage  of  carcinoma,  and  there  is 
no  bleeding  on  handling.  In  doubtful  cases  a  section  of  the  suspected 
tissue  should  be  submitted  to  the  microscope. 

Sarcoma  of  the  cervix  cannot  be  diagnosticated  from  carcinoma 
without  the  aid  of  the  microscope.  The  clinical  history  and  the  naked- 
eye  appearance  of  the  growth  will  riot  suffice  for  a  diagnosis. 

Abel  lately  claims  to  have  hit  upon  a  valuable  diagnostic  point 
in  squamous-cell  carcinoma  of  the  cervix.  He  finds  by  the  AYeigert 
resorcin-fuchsin  stain  the  presence  of  elastic  fibers  surrounding  the 
nests  of  the  epithelium  and  running  between  individual  epithelial  cells. 
In  benign  epithelial  growths,  such  as  condyloma  of  the  cervix  and 
papillary  erosions,  elastic  fibers  are  found  at  the  margins  of  epithelial 
groups  and  do  not  run  between  individual  cells. 

II.  Carcinoma  of  the  Cervix. — The  differential  diagnosis  of  carcinoma 
of  the  cervix  is  made  from  mucous  polyps,  submucous  fibroids,  and 
cystic  degeneration  of  the  glands  of  the  cervix.  In  all  of  these  the 
absence  of  friability,  the  slight  bleeding  when  handled,  and  a  micro- 
scopic examination  of  the  suspected  tissue  determine  conclusively  the , 
diagnosis. 

III.  Carcinoma  of  the  Body  of  the  Uterus. — The  differential  diagnosis 
of  carcinoma  of  the  body  of  the  uterus  is  from  endometritis,  submucous 
and  interstitial  fibroids,  retained  placental  tissue,  syncytioma  malig- 
num,  hydatiform  mole,  arteriosclerosis,  sarcoma,  and  endometritis. 

Endometritis  may  closely  resemble  carcinoma  of  the  body  of  the 
uterus  in  its  clinical  manifestations  and  in  its  macroscopic  and  micro- 
scopic appearances. 

The  syrriptoms  of  endometritis  may  be  identical  with  those  of  carci- 
noma. In  both  of  these  lesions  all  symptoms  may  be  absent  or  so 
insignificant  as  not  to  concern  the  patient. 

A  naked-eye  examination  of  the  endometrium,  after  removal  of  the 
uterus  or  of  scrapings  from  the  uterus,  while  sufficiently  characteristic 
in  many  cases,  may  be  altogether  misleading.  It  not  infrequently 
happens  that  the  only  way  to  make  a  positive  diagnosis  is  by  the  aid 
of  the  microscope. 

Indeed,  it  is  only  by  an  exploratory  curettage  and  a  microscopic  exami- 
nation of  the  scrapings  that  o.n  early  diagnosis  of  carcinoma  of  the  uterus 
can  he  made. 

Carcinoma  of  the  body  of  the  uterus  'is  so  insidious  in  its  development 
and  so  sloiv  in  its  progress  that  it  becomes  imperative  to  regard  with  sus- 
picion all  hemorrhages,  however  slight,  when  occurring  late  in  life,  and  to 
advise  an  exploratory  curettage  when  the  cause  of  the  hemorrhage  is  not 
accounted  for. 

In  making  'a  microscopic  examination  of  suspected  scrapings  from 
the  uterus  we  are  to  determine  whether  the  glands  are  more  irregular 
in  outline  than  the  glands  of  hyperplastic  and  hypertrophic  endo- 
metritis; whether  thev  are  so  increased  in  number  as  to  do  away  with 


654  CARCINOMA  OF  THE  UTERUS 

the  interglandular  connective  tissue  to  an  extent  not  observed  in 
endometritis,  and,  finally,  whether  the  epithelium  has  broken  through 
the  basement  membrane  and  is  found  within  the  interglandular  con- 
nective tissue.  These  three  findings — that  is,  great  irregularity  of 
the  glands,  great  increase  in  number  of  the  glands,  and  proliferation 
of  the  epithelium  beyond  the  basement  membrane — serve  to  distin- 
guish adenocarcinoma  and  malignant  adenoma  from  glandular  endo- 
metritis. One,  two,  or  all  three  of  these  features  may  be  found,  and 
are  to  be  regarded  as  characteristic.  The  last,  however,  is  by  far  the 
most  reliable.  Occasionally  there  will  be  found  a  specimen  the  char- 
acter of  which  cannot  be  determined  with  certainty.  Such  cases 
should  either  be  treated  as  if  malignant  or  should  be  kept  under  close 
observation. 

Submucous  and  interstitial  fibroids  may  present  all  the  clinical  evi- 
dences of  malignancy.  This  is  especially  true  in  gangrene  of  a  fibroid 
tumor.  Hemorrhage,  leucorrhea,  pain,  and  emaciation  may  all  be  in 
evidence,  and  suggest  the  presence  in  the  uterus  of  a  malignant  growth. 
An  exploratory  curettage  and  a  microscopic  examination  of  the  removed 
particles  will  establish  a  diagnosis. 

A  fibroid  bulging  into  the  uterine  cavity  may  be  identified  by  the 
sound,  curet,  or  the  examining  finger.  It  is  to  be  borne  in  mind  that 
fibroids  and  carcinoma  may  coexist  in  the  body  of  the  uterus,  and  we 
are  not  to  be  content  with  the  finding  of  any  single  cause  for  the 
symptoms,  but  are  to  exclude  all  possible  causes. 

Retained  ijlacental  tissiie  may  remain  in  the  uterus  an  indefinite 
length  of  time — weeks,  months,  and  years  after  the  termination  of 
labor  and  abortion.  Hemorrhage,  leucorrhea,  and  pain  may  result, 
giving  a  clinical  picture  that  may  be  mistaken  for  carcinoma  of  the 
body  of  the  uterus.  The  lesion  is  most  likely  to  be  found  during 
the  period  of  sexual  maturity,  while  the  symptoms  of  carcinoma  of  the 
uterine  body  seldom  appear  before  the  climacteric  period,  and  more 
often  some  time  after  the  menopause. 

A  positive  diagnosis  can  only  be  made  by  an  exploratory  curettage 
and  a  microscopic  examination  of  the  scrapings.  In  recent  cases  the 
placental  tissue  may  be  recognized  by  the  naked  eye,  but  in  cases  of 
long  standing,  mere  shadows  of  placental  tissue  may  be  recognized  by 
the  microscope.  The  presence  of  decidual  cells  and  chorionic  villi  in 
the  scrapings  determines  the  diagnosis. 

The  glands  of  pregnancy  are  so  varied  and  irregular  in  form  as  to 
suggest  the  possibility  of  malignancy  when  pregnancy  has  not  been 
suspected.  The  interglandular  connective  tissue  may  be  almost  entirely 
lost  by  pressure  of  the  enlarged  glands.  The  glands  seldom  run  at 
right  angles  to  the  surface  and  may  run  almost  parallel.  » Their  outlets 
are  constricted  by  the  surrounding  decidual  cells,  while  their  deeper 
portions  are  widely  distended.  As  a  rule,  a  single  layer  of  epithelium 
lines  them,  but  more  than  one  layer  is  occasionally  found.  The  epithe- 
lium is  flattened  or  cuboidal.  A  number  of  layers  of  flat  epithelium 
have  been  observed  in  the  glands.     There  is,  however,  no  invasion  of 


DIAGNOSIS  OF  EXTENSION  655 

the  interglandular  connective  tissue  by  the  epitheHum,  and  herein  lies 
the  differentiation  from  mahgnant  glands.  The  finding  of  decidual 
cells  surrounding  the  glands  will  suggest  their  character. 

Mucous  polyps  of  the  uterus  are  frequently  the  cause  of  hemorrhage. 
While  more  common  during  the  age  of  sexual  maturity,  they  may  be 
found  at  any  age,  even  years  after  the  menopause.  The  microscopic 
picture  does  not  differ  essentially  from  that  of  endometritis.  The 
absence  of  epithelial  proliferation  and  invasion  of  the  underlying 
connective  tissue  will  exclude  carcinoma. 

The  decidua  of  ectopic  pregnancy  may  be  confused  with  carcinoma 
when  pregnancy  is  not  suspected.  The  scapings  from  the  uterus  of 
an  ectopic  pregnancy  may  appear  to  the  naked  eye  not  unlike  those 
of  a  carcinoma.  Viewed  under  the  microscope  no  doubt  should  arise. 
In  association  with  the  decidual  cells  are  the  glands  of  pregnancy, 
giving  a  picture  not  to  be  confused  with  carcinoma. 

Tuberculous  endometritis  may  closely  simulate  carcinoma  in  its 
clinical  and  anatomical  features.  Tuberculosis  of  the  endometrium 
usually  occurs  early  in  life  as  compared  with  carcinoma  of  the  uterus. 
There  may  be  a  family  history  of  tuberculosis,  or  tuberculous  foci  may 
be  found  elsewhere  in  the  body.  If  found  in  the  tubes  it  is  suggestive 
that  the  endometrium  is  involved.  In  exceptional  cases  the  diagnosis 
can  be  made  from  cover-slip  preparations  of  the  leucorrheal  discharge. 
To  the  naked  eye  the  endometrium  may  present  characteristic  ulcers 
and  tubercles,  but  in  general  it  may  be  said  that,  in  the  absence  of 
tuberculosis  in  other  portions  of  the  genital  tract,  the  lesion  can  only 
be  diagnosticated  from  the  usual  forms  of  endometritis  or  carcinoma 
by  microscopic  examinations  of  sections  taken  from  the  uterus  after 
removal,  or  from  scrapings.  The  finding  of  tubercles,  giant  cells, 
or  tubercle  bacilli  and  the  absence  of  epithelial  invasion  of  the  con- 
nective tissue  will  complete  the  diagnosis.  The  picture  is  distinctly 
that  of  an  inflammatory  reaction. 

Diagnosis  of  Extension. — It  is  of  prime  importance  to  determine 
whether  or  not  the  carcinoma  is  confined  to  the  uterus.  This  should 
always  be  done  before  the  diagnosis  can  be  considered  complete  and 
before  determining  upon  radical  procedures  in  treatment. 

It  is  now  generally  conceded  that  the  entire  uterus  must  be  removed 
for  carcinoma  involving  any  part  of  the  organ;  hence  it  is  no  longer  a 
question  as  to  how  much  of  the  uterus  is  involved  in  the  growth,  but 
rather  as  to  whether  it  is  confined  to  the  uterus  or  has  spread  to  the 
surrounding  structures.  We  look  to  the  parametrium,  vagina,  bladder, 
rectum,  lymph  glands,  and  internal  organs  for  secondary  growths. 

The  parametrium,  particularly  that  portion  of  the  cellular  tissue 
found  between  the  layers  of  the  broad  ligaments,  is  usually  involved 
comparatively  early.  In  carcinoma  of  the  cervix  and  vaginal  portion 
the  base  of  the  broad  ligament  is  invaded.  Sampson  says  that  the 
parametrium  is  the  blood-vascular  and  lymph  hilus  of  the  uterus, 
in  that  it  is  in  direct  relation  with  the  cervix.  It  is  here  that  cancer 
of  the  cervix  first  spreads,  whether  the  extension  is  by  direct  continuity 


656  CARCINOMA  OF  THE   UTERUS 

of  tissues  or  by  metastasis.  Wertheim  found  the  parametrium  invaded 
in  47.5  per  cent,  of  his  cases,  and  in  more  than  half  of  this  number  the 
lymph  glands  were  not  involved.  The  infiltrated  tissue  is  felt  as  a 
"board-like"  mass,  irregular  and  nodular  in  outline,  firmly  fixed,  and 
not  tender  to  pressure.    The  cervix  is  crowded  in  the  opposite  direction. 

The  examination  is  best  made  under  anesthesia.  Two  fingers  are 
placed  in  the  rectum,  the  thumb  in  the  vagina.  Counter-pressure  is 
made  over  the  abdomen  by  the  other  hand.  The  cervix  and  area  of 
infiltration  will  be  found  as  one  mass.  The  cervix  will  be  immovable. 
This  immobility  of  the  cervix  does  not  necessarily  signif}^  a  carcino- 
matous invasion;  it  may  well  be  inflammatory. 

Inflammatory  swellings  of  the  tubes  and  ovaries,  fixed  by  the  side 
or  behind  the  uterus,  may  be  mistaken  for  carcinomatous  infiltration. 
Such  swellings  are  more  tender  to  pressure,  are  less  cartilaginous  in 
consistency,  have  not  the  same  intimate  connection  with  the  cervix, 
and  are  commonly  located  on  a  higher  plane. 

Still  greater  difficulty  is  experienced  in  differentiating  carcinomatous 
infiltration  of  the  parametrium  from  pelvic  cellulitis.  In  the  latter 
there  is  greater  tenderness,  the  outline  is  flatter  and  less  nodular,  and 
there  may  be  no  direct  and  immediate  connection  between  the  carci- 
nomatous lesion  in  the  uterus  and  the  infiltrated  parametrium.  The 
cervix  is  crowded  away  from  the  growth,  while  in  parametritis  the 
cervix  is  drawn  to  the  infected  side. 

It  is  difficult  to  demonstrate  carcinomatous  infiltration  of  the  con- 
nective tissue  occupying  the  vesico-uterine  space.  Usually  it  is  not 
possible  until  an  incision  is  made  into  the  region.  The  uterosacral 
ligaments  may  be  infiltrated.  The  characteristics  of  the  lesion  and 
the  differentiation  from  an  infiammatory  involvement  of  the  same 
structures  are  as  found  in  a  like  invasion  of  the  broad  ligaments. 

The  vagina  is  invaded  by  direct  extension,  seldom  by  metastasis. 

Since  carcinoma  of  the  vaginal  portion  more  often  begins  in  the 
anterior  lip,  the  anterior  wall  of  the  vagina  is  frequently  first  attacked. 
The  infiltrated  vaginal  wall  is  readily  recognized  by  the  finger  and  by 
examination  through  the  speculum.  The  infiltrated  area  in  the  vagina 
is  directly  continuous  with  the  growth  in  the  cervix.  The  margins 
of  the  infiltrated  area  are  elevated,  hard,  and  irregular.  Ulceration 
follows  in  the  late  stage,  and  such  ulcers  show  the  irregular,  elevated 
margins  and  the  uneven  base  which  bleeds  freely  on  being  touched. 
Metastatic  growths  may  be  found  at  any  point  in  the  vaginal  walls, 
more  often  in  the  posterior  wall.  Such  growths  are  hard  and  nodular, 
and  may  attain  the  size  of  a  walnut. 

When  the  paravaginal  tissue  is  infiltrated  it  is  possible  to  move  the 
vaginal  mucous  membrane  independently  of  the  underlying  growth. 

Syiegelherg's  sign  is  of  some  value  in  recognizing  a  carcinomatous 
infiltration  beneath  an  intact  mucous  membrane.  Passing  the  finger 
over  the  surface  the  mucous  membrane  feels  like  wet  rubber,  having 
lost  its  normal  pliability. 

Invasion  of  the  bladder  is  secondary  to  that  of  the  anterior  wall 


DIAGNOSIS  OF  EXTENSION  657 

of  the  vagina.  It  is  clinically  recognized  by  frequent  and  painful 
urination,  blood  in  the  urine,  and  finally,  by  the  dribbling  of  urine 
into  the  vagina  through  a  vesicovaginal  fistula.  An  early  diagnosis 
is  made  by  a  cystoscopic  examination.  The  area  of  infiltration  and 
the  ulcers  are  distinctly  seen,  and  when  associated  with  advanced 
carcinoma  of  the  cervix,  there  can  be  no  hesitancy  in  making  the  diag- 
nosis of  extension  of  the  carcinoma  to  the  bladder. 

The  rectum  is  invaded  after  the  growth  has  spread  to  the  posterior 
vaginal  wall.  The  symptoms  indicating  invasion  of  the  rectum  are 
a  mucous  discharge  which  is  often  stained  with  blood,  rectal  tenesmus, 
constipation  alternating  with  diarrhea,  and  a  discharge  of  feces  into 
the  vagina  after  the  development  of  a  rectovaginal  fistula.  A  digital 
exploration  of  the  rectum  and  vagina  reveals  a  hard,  infiltrated  area 
in  the  rectovaginal  septum,  which  bleeds  and  may  crumble  to  the 
touch;  the  mucous  membrane  of  the  rectum  has  lost  its  pliability,  and 
cannot  be  moved  independently  of  the  underlying  structures;  finally,  a 
section  removed  for  microscopic  examination  determines  the  diagnosis. 

Metastatic  growths  are  seldom  early  in  making  their  appearance. 
Experience  teaches  us  that  it  is  never  possible  to  say  with  absolute 
certainty  that  metastasis  has  not  occurred,  even  in  the  apparently 
early  growths.  The  ovary  is  sometimes  the  seat  of  metastasis.  Of 
the  abdominal  and  thoracic  viscera,  those  most  often  involved  are 
the  lungs  and  liver.  In  carcinoma  of  the  uterine  body  the  lumbar 
glands  are  first  involved.  If  the  horn  of  the  uterus  is  invaded  the 
deep  inguinal  glands  may  be  attacked  by  way  of  the  round  ligaments. 
In  carcinoma  of  the  cervix,  vaginal  portion  of  the  cervix,  and  upper 
segment  of  the  vagina,  the  iliac  glands  which  lie  in  front  of  the  sacro- 
iliac synchondrosis  at  the  bifurcation  of  the  common  iliac  vessels,  are 
first  invaded. 

In  carcinoma  of  the  vulva  and  lower  segment  of  the  vagina  the 
inguinal  glands  are  first  attacked.  It  is  of  the  greatest  importance  to 
recognize  involvement  of  the  lymphatic  glands  in  settling  the  question 
of  operative  interference. 

The  diagnosis  of  recurrence  after  removal  of  the  uterus  is  of  great 
importance.  A  recurrence  implies  failure  in  the  attempt  to  thoroughly 
remove  the  primary  focus. 

Winter  speaks  of  local  recurrence  when  the  secondary  development 
is  in  or  near  the  previous  field  of  operation;  of  lymph  gland  recurrence 
when  the  lymphatic  glands  of  the  body  are  involved  subsequent  to 
the  operation,  and  of  metastatic  recurrence  when  the  carcinoma  spreads 
to  distant  parts  of  the  body.  In  the  great  majority  of  cases  the  recur- 
rence is  local  and  multiple.  Hache  gives  the  following  statistics  relative 
to  the  time  of  recurrence  of  carcinoma  after  hysterectomy: 

Under  three  months 19.4  per  cent. 

Three  to  six  months 18.0  per  cent. 

Six  to  twelve  months 18.1  per  cent. 

One  to  two  years 22.3  per  cent. 

Two  to  three  years 14.6  per  cent. 

Over  three  years 7.6  per  cent. 

42 


658  CARCINOMA  OF  THE   UTERUS 

The  above  statistics  were  based  upon  a  study  of  144  cases.  Pamard 
reports  the  return  of  a  cervical  cancer  fifteen  years  after  removal 
of  the  primary  growth.  We  may  state  as  a  general  rule,  to  which  there 
are  few  exceptions,  that  recovery  is  assured  after  an  interval  of  five 
years  of  freedom  from  recurrence.  Early  recurrence  can  be  accounted 
for  by  the  failure  to  completely  remove  all  cancerous  tissue  in  the 
primary  operation.  It  is  not  so  easy  to  account  for  the  late  recurrences. 
We  may  say  that  the  cancerous  foci  have  remained  latent  in  the  tissues 
throughout  the  intervening  years,  but  such  an  assumption  is  scarcely 
tenable.  That  these  late  recurrences  may  be  independent  primary 
growths  no  one  can  deny. 

The  great  liability  of  recurrence  in  carcinoma  of  the  uterus  admonishes 
us  to  always  give  a  guarded  prognosis,  no  matter  how  early  and  thoroughly 
the  operation  may  have  been  performed. 

The  general  symptoms  indicating  a  recurrence  are  loss  of  flesh  and 
strength,  cachexia,  foul-smelling  leucorrhea,  irregular  hemorrhages, 
and  pain  in  the  pelvis  radiating  to  the  thighs,  groin,  rectum,  back, 
and  abdomen.  A  positive  diagnosis  can  only  be  made  from  a  physical 
examination.  Local  recurrence  in  the  tissues  about  the  uterus  is 
recognized  by  the  cartilaginous  consistency  of  the  areas  of  infiltration 
in  the  vagina  and  broad  ligaments. 

Granulation  tissue  in  the  scars  at  the  ends  of  the  stumps  previously 
anchored  in  the  vault  of  the  vagina  may  be  regarded  with  suspicion. 
They  are  seldom  so  hard  and  friable  as  carcinoma,  and  a  microscopic 
examination  of  an  excised  piece  or  scraping  will  determine  the  diag- 
nosis. It  is  not  always  possible  to  say  of  enlarged  glands  that  they 
are  so  from  carcinomatous  involvement.  It  is  possible  that  their 
enlargement  is  the  result  of  infection. 

Treatment. — Cancer  of  the  uterus,  in  its  inception  and  while  yet 
amenable  to  successful  treatment,  is  a  local  disease  and  demands 
typical  treatment. 

The  lesion  does  not  long  remain  confined  to  the  uterus,  and  hence  it 
follows  that  radical  removal  of  the  growth  is  only  possible  in  the  early 
stages  of  the  disease. 

When  surrounding  and  remote  structures  are  invaded  by  the  spread 
of  the  disease  through  lymph  and  blood  channels,  and  by  continuity  of 
tissue,  there  can  be  no  permanent  cure.  It  is  a  lamentable  fact  that 
fully  80  per  cent,  of  all  cases,  when  first  seen  and  recognized,  are  either 
inoperable  or  suffer  recurrence  after  operation  through  unrecognized 
invasion  of  neighboring  or  remote  structures. 

The  great  need  is  not  for  more  extended  operative  measures,  for  it 
would  appear  that  in  the  radical  abdominal  operation  the  limit  has 
been  reached,  but  there  is  need  for  earlier  recognition  of  cancerous 
growths  of  the  uterus. 

While  the  disease  is  still  confined  to  the  uterus  the  operative  pro- 
cedures at  our  command  afford  results  which  are  gratifying. 

Feio  would  die  from  cancer  of  the  uterus  if  the  disease  were  recognized 
in  time  and  surgery  early  invoked. 


TREATMENT  659 

The  greatest  obstacle  to  the  early  recognition  of  cancer  of  the  uterus 
is  the  misconception  that  is  entertained  by  the  laity,  and  by  some  of 
the  profession,  that  the  menopause  is  normally  marked  by  the  occur- 
rence of  irregular  menstrual  hemorrhages  and  leucorrheal  discharges. 
It  should  be  known  by  all  physicians,  and  the  information  should  be 
imparted  to  their  female  patients  who  are  in  the  midperiod  of  life,  that 
the  menopause  is  marked  by  a  gradual  diminution  of  the  menses  and 
by  an  increasing  interval  between  the  menstrual  periods;  that  every 
increase  in  the  menstrual  flow,  however  slight;  that  the  occurrence 
of  a  stain  of  blood  in  the  intermenstrual  period;  that  all  leucorrheal 
discharges,  especially  when  profuse,  watery  and  acrid,  are  suggestive 
of  malignancy  and  necessitate  an  immediate  searching  examination. 
"Women  should  be  advised  to  submit  to  an  examination  from  time  to 
time  while  passing  through  the  cancer  period  of  life,  just  as  one  goes  to 
the  dentist  for  inspection  of  the  teeth.  This  is  a  precautionary  measure 
of  the  highest  importance,  and  were  it  generally  adopted  fewer  cases 
would  escape  early  recognition  and  permanent  relief."     (Winter.) 

When  recognized  at  a  time  when  there  is  no  evidence  of  its  extension 
beyond  the  uterus  there  is  but  one  course  to  pursue,  that  of  inmiediate 
surgical  interference.  To  resort  to  such  conservative  measures  as  trypsin, 
amylopsin,  acetone,  the  .r-rays,  or  radium  is  homicide.  Such  measures 
are  only  to  be  adopted  when  surgery  has  failed  because  of  the  inoperable 
character  of  the  growth  or  because  of  its  recurrence  after  operation. 
Even  then  no  more  can  be  accomplished  by  the  employment  of  these 
remedies  than  the  checking  of  the  progress  of  the  disease  for  a  time, 
the  relief  from  some  of  the  disagreeable  symptoms,  and  the  giving  of 
encouragement  to  the  patient. 

How  can  ive  lessen  the  mortality  of  cancer  of  the  uterus  f  Montgomery 
says  that  if  we  accept  the  theory,  that  continued  irritation  favors  the 
development  of  malignant  disease,  then  in  order  to  prevent  its  occurrence 
or  limit  its  frequency  the  physician  must  institute  measures  to  avoid 
irritation  and  chronic  inflammation  of  the  pelvic  organs.  Injuries  to 
the  cervix  and  pelvic  floor  must  be  repaired.  Sources  of  irritation, 
such  as  displacements,  peri-uterine  inflammation,  and  uterine  myomata, 
particularly  of  the  submucous  and  interstitial  varieties,  are  sources  of 
irritation  and  must  be  eradicated. 

Oper ability  of  Cancer  of  the  Uterus. — Only  in  the  far-advanced  cases 
can  it  be  said  that  the  case  is  not  operable.  This  is  true  because  it  is 
known  that  cancer  of  the  uterus  may  remain  localized  for  a  surprisingly 
long  time;  that  in  such  cases  a  radical  operation  may  effect  a  cure  when 
least  expected,  or  at  least  stay  the  progress  of  the  disease  for  many  years. 

On  the  other  hand,  it  has  been  noted  that  at  an  early  time,  when 
the  growth  is  limited  in  its  extent,  the  parametrium  and  lymph  nodes 
of  the  pelvis  may  be  invaded. 

Such  is  the  uncertainty  of  judging  the  operability  of  cancer  of  the 
uterus,  and  the  more  so  of  cancer  of  the  cervix.  It  is  an  established 
fact  that  invasion  of  structures  lying  beyond  the  confines  of  the  uterus 
occurs  earlier  in  the  young  than  in  the  old. 


660  CARCINOMA  OF  THE   UTERUS 

It  is  encouraging  that  year  by  year  the  percentage  of  operable  cases 
is  increasing,  due  to  the  eariier  recognition  of  cancer  and  the  more 
extended  operations  now  in  vogue. 

Percentage  of  Operability  of  Cancer  of  the  Uterus. — We  find  great 
variation  in  the  percentage  of  operable  cases  of  cancer  of  the  uterus. 
The  percentage  ranges  from  5  to  92,  and  averages  about  65. 

In  2765  radical  abdominal  operations  for  cancer  of  the  uterus  by 
European  and  American  surgeons  the  average  primary  mortality  was 
19.45  per  cent.  This  primary  mortality  is  being  gradually  lowered. 
Death  in  the  majority  of  cases  is  due  to  sepsis  and  not  to  shock.  The 
presence  of  pyogenic  germs  in  the  cancer  tissue  is  largely  accountable 
for  the  infection.  Five  European  clinicians  show  an  average  of  40.72 
per  cent,  of  ultimate  cures.  In  these  cases  the  cancer  had  not  recurred 
within  five  years  of  the  operation.  In  contrast  with  these  statistics 
American  operators  show  but  8.39  per  cent,  of  cures  five  years  after 
operation,  with  only  1  per  cent,  of  "absolute  cures." 

Operative  Treatment  of  Cancer  of  the  Cervix. — Simple  Vaginal 
Hysterectomy. — Simple  vaginal  hysterectomy  for  cancer  of  the  cervix 
is  no  longer  regarded  with  favor,  for  the  reason  that  the  parametrium 
cannot  be  widely  excised.  The  operation  does,  however,  present  a 
relatively  low  mortality,  and  in  the  hands  of  the  inexperienced  operator 
will  afford  the  best  results.  There  are  cases  in  which,  for  reason  of 
the  difficulties  involved  in  an  abdominal  hysterectomy,  the  vaginal 
route  is  preferred.  We  know  from  our  studies  of  the  parametrium  and 
pelvic  lymph  nodes,  in  cases  of  cancer  of  the  uterus,  that  the  extent 
of  involvement  of  the  cervix  is  no  criterion  of  the  presence  or  absence 
of  cancerous  invasion  of  the  pelvic  lymph  nodes  and  parametrium, 
hence  the  inadvisability  of  choosing  the  restricted  operation  of  vaginal 
hysterectomy  in  early  cases,  in  preference  to  the  more  radical  abdominal 
operations. 

When  the  patient  is  too  weak  to  withstand  an  abdominal  operation, 
or  when  the  abdominal  wall  is  very  thick,  the  vaginal  route  may  well 
be  chosen.     (See  p.  681.) 

,  The  Byrne  -  Method  of  Treatment  of  Cancer  of  the  Cervix. — Before 
passing  to  the  discussion  of  the  radical  abdominal  operations  for 
cancer  of  the  cervix,  reference  will  be  made  to  the  Byrne  method  of 
treatment,  which  is  not  only  of  historical  interest,  but  still  reflects 
many  valuable  suggestions  worthy  of  serious  consideration.  Byrne, 
of  Brooklyn,  employed  the  galvanocautery  in  the  treatment  of  cancer 
of  the  cervix.    His  work  was  done  from  1872  to  1902. 

In  367  operations  for  cancer  of  the  uterus  he  had  no  operative  mor- 
tality. As  to  the  recurrences  following  his  operation  Byrne  states  that 
he  has  never  known  an  instance  of  relapse  in  which  the  disease  has 
returned  to  the  part  from  which  it  had  originally  been  excised.  He 
repeatedly  observed  the  reappearance  in  the  fundus,  ovaries,  and 
some  of  the  adjacent  tissues,  but  he  has  never  known  a  single  instance 
in  which  the  disease  has  reappeared  in  or  very  close  to  the  cauterized 
surface  from  which  the  cervix  had  been  removed  by  galvanocautery. 


OPERATIVE  TREATMENT 


661 


Contrast  these  results  with  those  of  Winter,  who  in  54  cases  out  of 
a  total  of  58,  observed  recurrences  at  the  site  of  excision.  From  this 
we  conclude  that  the  influence  of  the  cautery  extends  deep  into  the 
tissues,  unlike  that  of  the  knife  and  scissors. 

Of  Byrne's  367  cases  the  subsequent  history  was  known  in  216  cases, 
of  which  93  (43  per  cent.)  remained  free  from  recurrences  for  two  or 
more  years  and  22  (19  per  cent.)  for  five  and  more  years.  One  case  is 
now  living  and  free  of  recurrence  after  twenty-one  years. 

Fig.  435 


Schuchardt  operation:  Several  bullet  forceps  are  placed  equidistant  around  the  introitus.  A 
circular  incision  is  made  through  the  vaginal  wall  immediately  above  the  insertion  of  the  forceps 
and  several  centimeters  of  vaginal  wall  are  dissected  off  in  an  upward  direction.  This  cuff  is  closed 
with  silk  sutures,  in  leaving  the  sutures  long  for  purposes  of  traction.  The  bullet  forceps  are  removed. 
The  cancerous  area,  which  had  been  previously  excochleated  and  cauterized,  is  now  shut  off  from  the 
field  of  operation.     (Schauta.) 


Two  features  in  these  reports  are  particularly  noteworthy:  (1)  The 
absence  of  operative  mortality,  and  (2)  the  absence  of  recurrence 
at  the  point  of  cauterization.  While  somewhat  better  results  are 
claimed  for  the  late  radical  abdominal  operations,  no  operation 
has  yet  approached  the  Byrne  method  in  these  two  particulars. 

Werder  has  extended  the  original  Byrne  method.  He  has  extended 
it  from  a  high  amputation  of  the  cervix  to  vaginal  hysterectomy,  and 
is  thereby  able  to  exclude  the  recurrences  in  the  body  of  the  uterus 


662 


CARCIXOMA  OF  THE   UTERUS 


and  appendages.  He  first  amputates  the  cervix  with  the  cautery 
knife,  then  removes  the  body  of  the  uterus  and  adnexte  witli  the 
electrothermic  damp  of  Dou-nes. 

Schuchardt  Operation  Extended  Vaginal  Operation). — The  a])d()nhnal 
operation  for  cancer  of  the  uterus  was  being  extended  about  the  time 
(1893)  that  Schuchardt  extended  the  vaginal  operation. 

Fig.  436 


Schuchardt  operation:  The  dissection  of  the  vaginal  walls  is  carried  upward  to  the  vesicovaginal 
fold  and  the  bladder  stripped  away.  If  the  base  of  the  bladder  is  widelj-  infiltrated  the  operation 
should  not  proceed  further.  A  small  area  of  infiltration  in  the  base  of  the  bladder  may  be  excised  and 
the  opening  immediately  sutured.  The  Schuchardt  incision  is  now  made.  It  starts  from  the  left  and 
posterior  vaginal  walls,  extends  laterally  to  the  lower  end  of  the  labium  minus,  then  turns  downward 
parallel  to  the  rectum,  where  it  turns  inward  to  encircle  the  left  circumference  of  the  anus  and  ter- 
minates in  the  median  line  behind  the  anus.  The  incision  is  made  to  sever  the  following  structures: 
paravaginal  and  pararectal  tissues,  levator  ani  and  coccygeal  muscles,  cellular  tissues  of  the  ischiorectal 
fossa,  skin  of  the  perineum  and  lateral  anal  region  down  to  the  sacrum.  Care  should  be  exercised  to 
avoid  injurj-  to  the  rectum  and  sphincter  ani.  This  incision  freely  exposes  the  parametria,  within  easj' 
reach.  The  uterine  arterj-  and  veins  are  ligated.  The  ureter  is  now  in  full  \-iew  and  is  held  aside  by  a 
retractor.     (Schauta.) 


It  is  now  generally  conceded  that  it  is  impracticable  to  attempt  to 
remove  the  lymph  nodes  of  the  pelvis,  hence  the  maximum  of  endeavor 
is  to  remove  as  far  as  possible  the  parametrium.  If  this  can  be  done 
as  effectually  by  the  vaginal  route  as  by  the  abdominal,  the  choice 
would  be  in  favor  of  the  vaginal  operation,  because  of  the  lower  imme- 
diate mortality.    And  Schauta  claims  that  the  parametrium  and  vaginal 


OPERATIVE  TREATMENT 


663 


walls  can  be  removed  as  freely  by  the  vaginal  operation  as  by  the 
abdominal. 

Out  of  a  total  of  564  cases  of  cancer  of  the  uterus  which  presented 
in  the  clinic  of  Schauta  from  1901  to  1907,  258  were  operated  per 
vaginam  by  the  method  of  Schuchardt,  a  percentage  of  48.7  as  compared 
with  14.7  (Waldstein)  of  cases  operated  by  the  method  of  simple  vaginal 
hysterectomy.  In  the  extended  vaginal  hysterectomy,  cases  are  re- 
garded as  operable  when  the  vaginal  walls  and  parametrium  adjacent 


Schuchardt  operation:   The  cul-de-sac  of  Douglas  is  opened  and  the  parametria  is  excised  close  to  the 
pelvic  wall     Bleeding  can  be  controlled  by  ligatures  and  gauze  compresses.     (Schauta.) 


to  the  cervix  are  infiltrated,  while  in  simple  vaginal  hysterectomy, 
cases  are  regarded  as  inoperable  when  the  cancer  has  infiltrated  beyond 
the  limits  of  the  uterus.  No  attempt  is  made  to  perform  the  extended 
vaginal  operation  when  the  cancerous  infiltration  has  extended  to  the 
sides  of  the  pelvis,  but  there  is  no  limit  to  the  invasion  of  the  vaginal 
walls.  Schauta  has  performed  the  operation  in  the  presence  of  a  can- 
cerous involvement  of  the  entire  vagina  and  of  part  of  the  vulva.  A 
cystoscopic  examination  is  made  to  determine  the  possible  involvement 
of  the  bladder  before  deciding  upon  an  operation,  and  if  found  invaded 


664 


CARCINOMA  OF  THE   UTERUS 


the  operation  is  not  attempted.  Of  the  258  cases  operated  by  Schauta 
there  were  69  without  invasion  of  the  parametrium  and  179  in  which 
one  or  both  broad  hgaments  were  infiltrated.  The  mortahty  in  Schauta's 
cases  remains  at  10.3  per  cent,  in  the  extended  vaginal  operation,  which 
is  the  same  record  made  by  Schauta  in  the  simple  vaginal  operation; 
but  it  must  be  borne  in  mind  that  in  the  extended  vaginal  operation 
a  large  number  of  cases  are  operated  upon  which  would  have  been 
excluded  in  considering  the  simple  vaginal  operation. 


Fig.  438 


1 


l>ii  'C  urii,ana, 


Schuchardt  operation:  The  uterus  is  now  removed  and  interrupted  sutures  of  catgut  are  placed 
in  the  peritoneal  fold.  The  stumps  of  the  appendages  and  ligaments  are  brought  down  and  anchored 
in  the  lateral  angles  of  the  peritoneal  folds.     (Schauta.) 


As  to  the  percentage  of  recurrences  prior  to  the  end  of  the  second, 
third,  fourth,  and  fifth  years  following  operation  we  find  47.2,  43.7, 
44.0,  and  38.2  respectively. 

The  Schuchardt  operation  will  never  be  practised  extensively 
because  of  the  great  skill  demanded  in  its  proper  performance,  the 
high  primary  mortality  attending  the  operation,  and  the  large  per- 
centage of  serious  complications  and  sequelae  which  result   from  it. 


OPERATIVE  TREATMENT 


665 


Radical  Abdominal  Hysterectomy. — The  one  subject  of  paramount 
interest  to  the  gynecologist  is  the  radical  abdominal  operation  for 
cancer  of  the  uterus.  Not  only  the  uterus  and  its  adnexse  are  removed, 
but  the  effort  is  made  to  remove  as  far  as  possible  the  pelvic  tissues 
involved  in  the  extension  of  the  growth,  that  is,  the  pelvic  lymph 
nodes,  parametrium,  upper  segment  of  the  vagina,  and  broad  ligaments. 


Fig.  439 


Sohuchardt  operation:   The  cavity  beneath  the  peritoneal  fold  is  loosely  packed  with  gauze,  and 
the  paravaginal  incision  is  closed  with  buried  and  superficial  sutures.     (Schauta.) 


The  first  attempt  to  eradicate  the  disease  by  an  extended  abdominal 
operation  was  made  by  Freund  in  1878.  Since  then  the  Freund  opera- 
tion has  been  modified  in  the  effort  to  remove  pelvic  tissues  remote  from 
the  primary  lesion.  With  each  advance  in  this  direction  the  operative 
mortality  has  been  increased  and  the  percentage  of  recurrence  has 
been  lessened.  At  the  present  writing  it  is  no  longer  an  open  question 
as  to  whether  the  improved  remote  results  justify  the  high  rate  of 
operative  mortality.  We  must,  in  all  fairness,  encourage  the  work  of 
Wertheim,  Clark,  Sampson,  Ries,  and  others,  who  are  pursuing  their 
investigations,  for  we  recall  the  words  of  the  late  Reeves  Jackson, 
who  less  than  a  score  of  years  ago  condemned  vaginal  hysterectomy 


666  CARCINOMA  OF  THE   UTERUS 

for  cancer  of  the  cervix  as  a  "murderous  operation."     "We  therefore 
await  the  ultimate  solution  of  the  problem  without  prejudice. 

Vaginal  hysterectomy  for  cancer  of  the  cervix  has  been  largely 
abandoned  because  of  the  high  rate  of  recurrence  within  a  comparatively 
short  time.  The  profession  has  come  to  the  almost  unanimous  con- 
clusion that  the  route  of  choice  is  the  abdominal,  but  there  is  a  great 
diversity  of  opinion  as  to  the  extent  to  which  the  abdominal  operation 
should  be  carried. 

To  what  extent  should  the  dissection  of  pelvic  tissues  be  carried f 
To  arrive  at  a  satisfactory  answer  to  this  important  question  we 
must   consider : 

1.  The  frequency  of  recurrence  in  the  ^"arious  pelvic  tissues  which 
permit  of  removal. 

2.  The  operati^'e  mortality  in  the  various  steps. 

3.  The  percentage  of  recurrences  in  operations  carried  to  the  various 
degrees  of  dissection. 

The  operative  mortality  has  been  unquestionably  increased  by  the 
effort  to  remove  the  pelvic  lymph  glands.  In  31.7  per  cent,  of  60  cases, 
operated  by  Wertheim,  the  peh'ic  lymph  glands  were  found  to  contain 
cancer  cells,  hence  his  practice  of  removing  them  as  far  as  possible; 
yet  we  have  the  word  of  ^Yertheim,  himself,  that  in  every  case  in  which 
the  removed  glands  were  found  the  seat  of  metastasis — there  was  recur- 
rence. ^Miy  then,  we  ask,  should  such  an  operation  be  persisted  in 
when  the  operative  mortality  is  so  much  higher  than  in  the  less  radical 
operation  which  stops  short  of  removing  the  lymph  nodes?  It  is  further 
reassiu'ing  to  note  that  Winter  and  Cullen  do  not  share  in  the  findings 
of  Wertheim.  They  found  but  2  per  cent,  of  their  cases  with  glandular 
involvement. 

The  author  is  forced  to  take  the  position  of  Clark  and  a  host  of  able 
operators,  that  the  removal  of  the  lymph  glands  is  not  justified  in  view 
of  the  high  operative  mortality  and  the  high  percentage  of  recurrence 
in  cases  in  which  the  removed  glands  are  cancerous. 

The  enthusiasts  for  the  extended  operation  must  admit  the  utter 
impossibility  of  removing  all  lymph  glands  of  the  pelvis,  and  hence 
the  unfairness  of  comparing  the  radical  operation  for  cancer  of  the 
breast  with  that  of  cancer  of  the  cervix.  • 

Those  glands  which  can  be  removed  are  the  sacral  glands  found 
on  the  anterior  surface  of  the  sacrum  and  in  the  mesorectum,  and  the 
iliac  glands  found  in  the  triangle  between  the  external  and  internal 
iliac  vessels.  But  we  cannot  remove  the  glands  along  the  course  of 
the  aorta  and  renal  vessels. 

In  253  cases  of  cancer  of  the  cervix,  histological  examinations  of  the 
pelvic  connective  tissue  were  made  by  Kermauner,  Lameris,  Brunet, 
Pankow,  and  Kundrat,  and  cancerous  invasion  of  the  parametrium 
was  found  in  172  (67.6  per  cent.).  Both  sides  of  the  pelvis  were  as 
frequently  involved  as  one  side;  the  left  side  more  often  than  the 
right.  In  but  21  per  cent,  of  Pankow's  cases  was  it  possible  to  recognize 
the  invasion  clinicallv. 


OPERATIVE  TREATMENT  667 

The  manner  of  invasion  was  by  continuity  of  tissue  or  by  metastasis. 
Brunet  observed  that  the  invasion  by  continuity  of  tissue  occurred 
in  one  of  several  ways:  either  by  passing  directly  through  the  uterine 
wall  by  way  of  the  uterine  ligaments,  or  by  way  of  the  lymph  channels 
of  the  bloodvessel  walls  and  nerve  sheaths.  In  about  one-third  of  the 
cases  the  connective  tissue  was  invaded  by  metastasis  by  way  of  the 
lymph  and  blood  streams. 

In  no  cases  of  cancer  of  the  corpus  was  the  connective  tissue  of  the 
pelvis  invaded. 

It  is  observed  that  the  glands  are  involved  relatively  late  in  squamous- 
cell  carcinoma,  and  in  old  individuals  as  compared  with  the  young. 

Should  the  glands  alone  be  removed  or  should  the  connecting  lymph 
channels  be  removed  with  themf 

Histological  observations  point  to  the  invasion  of  lymph  channels 
as  well  as  lymph  glands;  hence  if  the  glands  are  to  be  removed  the  lymph 
channels  must  be  removed  with  them.  Kromer,  Schauta,  Schmidler, 
Lameris,  and  Kermauner  have  all  observed  cancer  cells  in  the  neighbor- 
hood of  lymph  nodes.  It  is  at  once  apparent  that  the  removal  of  all 
lymph  nodes  and  lymph  channels  is  an  impossibility,  hence  the  futility 
of  the  procedure. 

Brunet  found  the  paravaginal  tissue  invaded  with  cancer  cells  33 
times  in  70  cases,  and  in  two-thirds  of  these  cases  the  superficial  layers 
of  the  vagina  were  free  of  invasion.  This  emphasizes  the  unreliability 
of  judging  the  extent  of  the  invasion  from  clinical  and  macroscopic 
findings,  and  it  speaks  for  the  advisability  of  removing  at  least  the 
upper  segment  of  the  vagina  in  all  radical  operations  for  cancer  of 
the  cervix. 

jNIetastasis  rarely  occurs  in  the  tubes  and  ovaries  in  cancer  of  the 
cervix,  but  has  occasionally  been  found  in  cancer  of  the  body  of  the 
uterus;  hence  the  advisability  of  removing  the  appendages  in  cancer 
of  the  body  of  the  uterus. 

The  glands  on  the  side  of  greatest  involvement  of  the  parametrium 
may  be  free  and  on  the  other  side  the  seat  of  metastatic  foci.  As  yet 
we  are  not  able  to  distinguish  between  the  various  types  of  cases  as 
regards    metastasis. 

Preparation  of  Patient  for  Operatio7i.— When  the  patient  is  impov- 
erished in  blood  and  exhausted  in  strength,  the  radical  abdominal 
operation  is  attended  with  great  risk  to  life.  In  these  cases  a  preliminary 
curettage  and  cauterization  of  the  cancerous  area,  followed  by  rest  in 
bed,  forced  feeding,  and  the  administration  of  tonics,  will  prepare  the 
patient  to  withstand  the  prolonged  operation. 

Wertheim  and  Clark  advise  a  preliminary  cauterization  of  the 
cancerous  growth  before  proceeding  with  the  abdominal  operation. 
All  may  be  done  under  a  single  anesthesia,  or  the  cauterization  may 
precede  the  abdominal  operation  by  several  days. 

A  blood  examination  should  be  made  to  determine  the  degree  of 
anemia.  In  so  doing  a  radical  operation  may  be  postponed,  and  thus 
stay  for  a  time  an  operation  that  might  otherwise  prove  fatal. 


668  CARCIXOMA   OF   THE    UTERUS 

A  twenty-four  hour  specimen  of  urine  sliould  be  examined  as  a  guide 
to  the  possible  occlusion  of  the  ureter. 

Techiic  of  the  Radical  Operation. — As  a  precautionary  measure  the 
ureteral  catheter  may  be  passed  into  each  ureter  and  left  there  as  a 
guide  to  the  course  of  the  ureters.  The  danger  of  injuring  the  ureters 
will  be  greatly  lessened  thereby.  This  should  be  done  before  the  general 
anesthetic  is  started. 

AVith  added  experience  the  preliminary  catheterization  of  the  ureters 
will  be  less  necessary  and  may  be  confined  to  the  cases  in  which  the 
peri-ureteral  tissues  are  infiltrated. 

A  liberal  abdominal  incision  is  made  from  the  umbilicus  to  the 
s\Tnphysis  pubis.  After  opening  the  abdomen,  the  upper  abdominal 
viscera,  especially  the  liver,  should  be  palpated  in  view  of  possibly 
finding  metastasis.  It  is  known  that  meta.-tatic,  cancerous  foci  may 
exist  in  the  liver  and  elsewhere  when  the  primary  lesion  in  the  uterus 
appears  operable. 

Fig.  440 


--.  / 


Radical  abdominal  operation  for  cancer  of  the  uterus.     Step  1.    The  uterus  is  grasped  bj-  a  heavy 
tenaculum  forceps  and  drawn  to  one  side  while  being  elevated.     (After  Kellj-.) 

Having  exposed  the  pelvis  to  view,  a  preliminary  digital  examination 
should  be  made  with  as  much  haste  as  is  consistent  with  thoroughness. 
The  broad  ligaments  are  embraced  by  the  index  finger  and  thumb 
and  palpated  from  the  uterus  outward  to  the  sides  of  the  pelvis  for 
the  purpose  of  noting  areas  of  induration.  Likewise  the  uterosacral 
ligaments  are  palpated  and  a  careful  search  is  made  for  enlarged  glands. 
If  no  widespread  extension  can  be  discerned  in  this  manner  the  radical 
operation  may  be  proceeded  with,  but  if  the  extension  of  the  growth 
is  beyond  the  limits  of  the  operation  no  good  can  come  from  such  a 
procedure.     It  is  then  advisable  to  do  no  more  than  a  simple  hyster- 


OPERATIVE  TREATMENT 


669 


ectomy  or  to  close  the  abdominal  incision  without  interference  and 
to  cauterize  the  cervix. 

If,  because  of  the  limited  extent  of  the  involvement,  it  is  determined 
to  proceed  with  the  radical  operation  the  work  must  progress  speedily, 
for  at  best  the  operation  is  long  and  depressing  to  the  patient.  To  guard 
against  shock,  hot-water  bottles  are  placed  about  the  patient  and  the 

Fig.  441 


Radical  abdominal  operation  for  cancer  of  the  uterus.  Step  2.  Ligatures  are  placed  about  the 
round  ligaments  and  infundibulopelvic  ligaments.  The  appendages  are  dissected  from  the  broad 
ligaments.  The  broad  ligament  is  split  and  so  dissected  as  to  expose  the  ureters  and  uterine 
arteries.      (After  Kelly.) 


bowels  are  carefully  covered  with  hot  sterile  packs.  The  fundus  is 
grasped  by  heavy  vulsellum  forceps  and  traction  is  made  upward  and 
outward,  opposite  to  the  side  on  which  the  first  incision  is  made.  The 
initial  incision  is  that  suggested  by  Wertheim,  and  is  made  through  the 
peritoneum  from  the  bifurcation  of  the  common  iliac  artery  downward 
and  inward  to  the  point  of  entrance  of  the  ureters  into  the  bladder 
(Fig.  441).  .  '       ■  ■ 


670 


CARCINOMA  OF  THE   UTERUS 


Clark  next  advises  to  ligate  the  infundibulopelvic  ligaments  at  the 
pelvic  brim,  placing  a  double  ligature  and  cutting  between.  The  round 
ligaments  are  then  ligated  one  inch  from  their  attachment  to  the  uterus 
and  the  ligament  severed.  Having  made  the  two  lateral  incisions 
through  the  peritoneum  along  the  course  of  the  ureters  and  severed 
the  infundibulopelvic  and  round  ligaments  on  either  side,  the  next 
step  is  to  extend  the  peritoneal  incisions  around  the  uterus  in  front, 


Fig.  442 


Radical  abdominal  operation  for  cancer  of  the  uterus.  Step  3.  The  peritoneum  and  bladder  are 
stripped  from  the  cervix;  the  uterine  artery  is  severed  between  two  ligatures  and  the  ureter  is  pushed 
far  to  one  side.      (After  Kelly.) 


at  a  point  above  the  attachment  of  the  bladder.  With  the  uterus 
retracted  backward  and  upward,  the  bladder  is  stripped  downward, 
exposing  the  cervix  and  anterior  vaginal  wall.  The  ureters  should  now 
be  carefully  located;  this  is  not  a  difficult  task  if  catheters  are  in  place. 
They  are  crowded  outward  and  the  uterine  arteries  ligated  and  severed 
on  either  side.  The  only  remaining  supports  to  the  uterus  are  the 
vaginal  walls  and  uterosacral  ligaments. 


OPERATIVE  TREATMENT 


671 


The  peritoneum  back  of  the  cervix  is  next  incised  and  stripped 
do^\Tiward  away  from  the  cervix.  Next  the  uterosacral  Hgaments  are 
Hgated  and  cut  close  to  their  attachment  to  the  sacrum. 

The  right  angle  clamps  used  b}'  Wertheim  are  now  made  to  compress 
the  vaginal  walls  at  a  low  level.  (See  Fig.  447.)  The  vagina  is  then 
severed  between  the  clamps  by  a  galvanocautery  knife.  The  denuded 
surfaces  are  then  charred,  taking  care  to  avoid  injury  to  the  ureters. 

Fig.  443 


Radical  abdominal  operation  for  cancer  of  the  uterus.  Step  4.  The  uterus  is  brought  well 
forward  and  upward  and  the  peritoneum  incised  behind  the  cer^'ix  and  stripped  downward,  exposing 
the  vaginal  walls. 


bladder,  and  rectum.  The  vagina  is  closed  below  the  clamps  with 
running  or  interrupted  plain  catgut  sutures.  The  peritoneal  incisions 
are  closed  with  running  sutures  of  Xo.  1  plain  catgut. 

Postoperative  Cystitis  and  Ureteral  Fistula. — Cystitis  is  a  common 
sequel  to  the  radical  operation  for  cancer  of  the  cervix,  for  the  reason 
that  the  blood  and  nerve  supply  to  the  bladder  are  extensively  involved 
in  the  operation.    The  diminished  blood  supply  and  the  loss  of  tone 


672 


CARCINOMA  OF  THE  UTERUS 


of  the  bladder  wall  predispose  to  infection  in  that  retention  of  urine 
so  commonly  results.  It  has  been  advised  to  circumvent  the  develop- 
ment of  cystitis  when  retention  of  urine  follows  this  operation  by  occa- 
sionally irrigating  the  bladder.  When  cystitis  develops,  treatment  is 
along  the  usual  lines. 


Fig.  444 


Radical  abdominal  operation  for  cancer  of  the  uterus.  Step  5.  The  peritoneum  is  stripped  from  the 
uterus  on  all  sides,  laying  bare  the  supravaginal  portion  of  the  cervix,  upper  segment  of  the  vagina, 
ureters,  and  pelvic  connective  tissue.     (After  Kelly.) 


~  A  uretheral  fistula  may  be  the  result  of  direct  injury  to  the  ureter  or 
to  the  blood  supply  to  the  ureter.  The  fistula  may  heal  spontaneously 
or  may  persist  indefinitely,  requiring  the  transplantation  of  the  ureter 
into  the  bladder,  or  in  case  of  infection  of  the  ureter  and  kidney,  a 
nephrectomy  may  be  demanded. 

Kelly  speaks  of  the  remarkable  fact  that  there  may  be  few  symptoms 
to  mark  the  accidental  ligation  of  the  ureters,  that  there  may  be  no 
pain  or  discomfort,  or  that  the  symptoms  may  be  so  slight  as  to  be 


OPERATIVE  TREATMENT 


673 


masked  by  the  ordinary  events  of  the  postoperative  period.    The  pain 
in  the  kidney  may  be  intense,  demanding  relief. 

In  Wertheim's  series  of  500  cases  the  primary  mortality  was  exces- 
sive. In  the  first  100  cases  the  death-rate  was  30  per  cent.;  in  the 
second  series  of  100  cases  it  was  22  per  cent.,  and  in  the  last  series  of 

Fig.  445 


Radical  abdominal  operation  for  cancer  of  the  uterus.  Step  6.  The  vaginal  walls  are  clamped 
below  the  cervix  and  severed,  and  the  uterus,  together  with  a  portion  of  the  vagina,  is  then  freed 
completely.  In  removing  the  uterus,  as  much  as  possible  of  the  connective  tissue  is  removed  together 
with  the  uterus  without  doing  injury  to  the  ureters.  The  operation  is  completed  as  in  total  abdominal 
hysterectomy.     (After  Kelly.) 


100  cases  it  was  15  per  cent.   It  would  not  be  amiss  to  contemplate  the 
frightful  mortality  attending  such  an  operation  in  less  skilful  hands. 

But  it  is  not  alone  the  primary  mortality  of  this  operation  that 
appalls  us,  for  there  are  many  serious  complications  attending  the 
operation.    Clark  refers  in  this  connection  to  the  statistics  of  Rosthorn, 
43 


674 


CARCINOMA  OF  THE   UTERUS 


who  operated  in  256  cases  in  which  the  bladder  was  injured  41  times 
(16.41  per  cent.),  the  ureters  were  injured  in  6.25  per  cent.,  the  rectum 
was  torn  in  3  per  cent.,  secondary  necrosis  of  the  bladder  occurred  in 
6.25  per  cent.,  and  secondary  ureteral  fistulse  developed  in  7.05  per 
cent,  of  cases.  In  addition  to  these  complications  and  sequelae,  there 
was  a  small  percentage  of  intestinal  fistulse  and  other  complications. 


Fig.  446 


Uterine  arteries  ligated  and  cut.     Uterosacral  ligaments  (a)  ligated.     Dotted  line  in  Pouglas' 
cul-de-sac  indicates  the  course  of  the  peritoneal  excision.     (Kelly-Noble.) 

A  review  of  the  literature  demonstrates  the  fact  that  along  with  the 
lowering  of  the  percentage  of  recurrences  in  cases  in  which  the  Wer- 
theim  operation  has  been  performed,  there  has  been  a  corresponding 


OPERATIVE  TREATMENT 


675 


increase  in  the  primary  mortality  and  in  the  percentage  of  serious 
compHcations.  So  true  is  this  that  one  must  seriously  consider  whether 
the  procedure  is  really  justified. 


Fig.  447 


Uterus  dissected  free  from  the  bladder  and  cut  away  from  its  sacral  attachment.  The  uterus  is 
drawn  well  up  toward  the  umbilicus,  while  special  right-angled  clamps  are  applied,  which  clear  the 
ureters  and  securely  close  the  vagina.     (Kelly-Noble.) 


676  CARCINOMA   OF   THE   UTERUS 

A  review  of  the  statistics  on  the  prognosis  of  cancer  of  the  uterus 
reveals  a  great  dift'erence  in  the  results  of  operators.  This  fact  is  largely 
accounted  for  by  the  selection  of  cases,  rather  than  by  the  skill  of  the 
operator.  In  the  German  clinics  the  statistics  arg  better  than  in 
America,  because  in  Germany  a  larger  percentage  of  cases  seek  opera- 
tion in  the  early  stages  of  the  disease. 

Primary  Mortality  following  the  Extended  Abdominal  Operation  for 
Cancer  of  the  Cervix. — The  combined  statistics  of  twelve  German  clinics, 
including  a  total  of  2223  operated  cases,  show  an  average  primary 
mortality  of  18.86  per  cent.  In  298  operations  performed  in  America 
there  was  a  primary  mortality  of  15.7  per  cent.  In  a  total  of  23  cases 
operated  by  Taussig  there  was  an  operative  mortality  of  8  per  cent, 
in  cases  not  far  advanced  as  contrasted  with  72  per  cent,  in  cases  that 
were  far  advanced. 

Percentage  of  Absolute  Cures  following  the  Radical  Abdominal 
Operation. — The  combined  statistics  of  six  of  the  German  clinics  show 
an  average  of  17.42  per  cent,  of  absolute  cures  following  the  radical 
abdominal  operation. 

Taussig,  in  reporting  the  results  of  eight  Western  surgeons,  gives 
9.0  per  cent,  of  absolute  cures. 

Treatment  of  Cancer  of  the  Cervix  Complicating  Pregnancy. — 1. 
AMien  the  cancer  appears  operable,  no  time  should  be  lost  in  removing 
the  uterus.  If  the  fetus  is  viable,  a  Cesarean  section  should  precede 
hysterectomy.  If  the  child  is  not  viable,  hysterectomy  should  be 
performed  without  removing  the  fetus.  To  first  empty  the  uterus 
would  subject  the  patient  to  an  unnecessary  loss  of  blood. 

2.  ^Yhen  the  cancer  is  inoperable,  the  life  of  the  child  is  to  be  con- 
sidered and  every  effort  made  to  continue  the  pregnancy  to  term. 
When  this  period  is  reached,  the  child  should  be  deli^'ered  by  Cesarean 
section  and  the  uterus  removed  if  the  condition  of  the  patient  will 
permit.  As  a  rule  a  supravaginal  hysterectomy  is  the  operation  of 
choice;  this  is  done  to  lessen  the  danger  of  infection.  Delivery  through 
the  natural  passage  gives  added  danger  to  the  mother  because  of  the 
liability  to  rupture  of  the  uterus,  serious  hemorrhage,  and  sepsis. 
If  the  fetus  dies  in  utero  the  uterus  should  be  amputated  above  the 
cervix,  and  if,  in  the  course  of  pregnancy,  the  health  of  the  mother 
fails  rapidly,  there  is  little  hope  of  carrying  the  child  to  term.  In  this 
event  the  strength  of  the  mother  should  be  kept  up  in  every  possible 
way,  in  the  hope  of  being  able  to  deliver  a  viable  child. 

Palliative  Treatment. — Palliative  treatment  is  demanded  when  the 
mother  suffers  from  pain,  hemorrhage,  and  foul  discharges.  The  pain 
should  be  relieved  by  heroine,  codeine,  small  doses  of  morphine,  or 
rectal  suppositories  of  opium.  If  the  discharges  cannot  be  controlled 
by  antiseptic  vaginal  douches,  preferably  of  formalin,  1  to  1000,  and 
the  hemorrhages  are  great  and  uncontrollable,  the  cervix  should  be 
curetted  and  cauterized.  This  will  probably  provoke  a  miscarriage, 
but  under  such  circumstances  there  is  little  prospect  of  a  viable  child. 
If,  however,  these  conditions  arise  near  the  time  of  labor,  the  curet 
and  cautery  should  not  be  emplo}'ed  until  labor  is  terminated. 


OPERATIVE  TREATMENT  677 

Treatment  of  Inoperable  Cancer  of  the  Cervix. — A  review  of  the 
literature  convinces  one  that  much  can  be  done  to  prolong  life  and  relieve 
suffering  in  this  unfortunate  class  of  cases.  By  scraping  away  all 
friable  tissue  and  vigorously  applying  the  Paquelin  cautery,  the  bloody 
and  leucorrheal  discharges  are  checked,  and  if  this  procedure  is  repeated 
when  the  discharges  return,  it  is  possible  to  prolong  life  in  comparative 
comfort  for  months  and  probably  years.  In  408  cases  reported  by  Blau 
there  was  an  average  of  2,52  days  of  life  after  the  initial  curettement 
and  cauterization.  Pawlick  records  the  case  of  a  patient  who  lived 
twenty-one  years  after  the  initial  treatment.  In  the  experience  of 
Conrad  there  was  an  average  of  525  days  of  life  in  cases  treated  with 
chloride  of  zinc  and  pyoktanin.  Tomer  recorded  119  cases  treated 
by  the  Paquelin  cautery  that  were  apparently  healed  after  five  years. 
These  statistics  speak  for  the  value  of  local  applications  in  the  manage- 
ment of  cancer  of  the  cervix,  which  is  so  far  advanced  as  to  be  no  longer 
operable.  We  are  seriously  handicapped  in  the  management  of  these 
cases  because  of  our  inability  to  pursue  a  definite  line  of  treatment 
for  the  required  time.  Our  hospitals  do  not  wish  to  harbor  these  cases 
and  too  often  these  patients  are  lost  sight  of.  The  need  is  for  hospital 
accommodations  for  such  cases,  in  which  isolated  wards  are  provided 
and  every  facility  afforded  for  their  care. 

Gellhorn  Treatment. — For  the  past  three  years  the  author  has  followed 
the  suggestion  of  Dr.  George  Gellhorn  in  curetting  and  applying  acetone 
to  the  excochleated  area. 

The  method  consists  in  thoroughly  scraping  away  all  friable  tissue, 
then  elevating  the  hips  of  the  patient  and  introducing  about  one  ounce 
of  acetone  through  a  Ferguson  speculum.  The  anesthetic  is  stopped, 
and  at  the  end  of  twenty  to  thirty  minutes,  the  acetone  is  decanted  by 
lowering  the  hips.  A  long,  narrow  strip  of  sterile  gauze  is  soaked  in 
acetone  and  packed  into  the  excochleated  area,  and  in  front  of  this 
is  inserted  a  tampon  smeared  with  sterile  vaseline. 

Subsequent  treatments  are  given  two  or  three  times  a  week,  and 
later  at  longer  intervals.  Xo  anesthetic  is  required  for  these  treatments. 
Great  caution  must  be  exercised  in  preventing  the  acetone  from  coming 
in  contact  with  the  vulvar  surfaces.  These  should  be  smeared  heavily 
with  vaseline,  the  hips  elevated,  and  a  Ferguson  speculum  inserted  into 
the  cancerous  cavity.  The  speculum  is  then  partly  filled  with  acetone 
and  the  patient  directed  to  hold  the  speculum  in  place  for  twenty  to 
thirty  minutes.  As  the  crater  diminishes  in  size,  smaller  specula  are 
used.  In  the  intervals  between  treatments,  antiseptic  vaginal  douches 
are  given. 

In  my  experience  with  the  acetone  treatment  the  hemorrhages  do 
not  recur,  the  discharges  disappear  almost  completely,  and  the  crater 
at  the  vault  of  the  vagina  is  greatly  constricted.  Not  infrequently  a 
smooth  scar  is  left  in  the  vault  of  the  vagina.  It  is  not  claimed  for 
this  treatment  that  it  will  relieve  pain  or  stay  the  progress  of  the 
malignant  invasion  of  tissues,  but  it  does  prolong  life  and  promotes 
comfort. 


678 


CARCINOMA  OF  THE   UTERUS 


To  control  the  pain  the  author  does  not  hesitate  to  give  the  needed 
opiates.  He  is  in  the  habit  of  beginning  with  aspirin,  10  grains,  or 
heroine  in  yV  to  ^-grain  doses,  and  when  this  fails,  to  begin  with  morphine 
in  as  small  doses  as  will  render  the  patient  free  of  pain. 

The  strength  of  the  patient  must  be  kept  up  by  nourishing  food  and 
the  administration  of  tonics.  All  manner  of  means  must  be  employed 
to  interest  the  patient  and  to  keep  her  buoyant  in  spirits.  It  is  a 
questionable  practice  to  prolong  life  when  the  patient  is  suffering,  as 
they  so  often  do,  in  the  last  stages  of  cancer  of  the  cervix. 

Fig.  448 


Introduction  of  the  Ferguson  speculum. 


Prognosis. — At  the  present  time  cancer  causes  more  deaths  in  women 
than  does  tuberculosis.  Clark  says:  "A  careful  analysis  of  the  statistics 
of  cancer  which  are  obtainable  at  the  present  time  forces  one  to  the 
conclusion  that  there  is  a  constant  and  considerable  increase  in  the 
number  of  people  afflicted  with  cancer  in  all  civilized  countries."  The 
time  when  a  patient  who  has  been  operated  for  cancer  of  the  uterus 
may  be  pronounced  cured  is  arbitrarily  placed  at  five  years,  though 
it  is  understood  that  recurrence  may  take  place  at  a  later  date.  The 
difficulty  of  following  the  cases  in  after  years  accounts  for  the  unsatis- 
factory statistics  in  cancer  cases. 

We  have  the  report  of  Baldy  in  support  of  Cullen,  who  says  that 
not  more  than  5  per  cent,  of  cases  of  cancer  of  the  cervix  are  cured. 
In  contrast  to  the  discouraging  statistics  of  the  above  authors  we 
find  Leopold  claiming  43.2  per  cent  of  cures  and  Kaltenbach  13.9  per 
cent. 

It  is  noted  that  the  older  the  individual,  the  less  the  chance  of  recur- 


OPERATIVE  TREATMENT 


G79 


rence.  Pregnancy  complicating  cancer  of  the  cervix  presents  a  most 
favorable  condition  for  the  extension  of  cancer  because  of  the  great 
vascularity  of  the  tissues  and  the  active  lymph  channels.  The  great 
need  is  for  an  early  diagnosis,  and  when  made  the  necessary  operative 
measures  will  not  be  wanting,  -and  the  results  will  be  more  and  more 
encouraging. 

Fig.  449 


Vaginal  hysterectomy.  Step  1.  A  weighted  speculum  below  and  a  retractor  above  exposes  the 
cer^'ix.  Th^  cervix  is  grasped  by  a  tenaculum  forceps  and  firm  traction  is  made  upon  the  uterus. 
A  circular  incision  is  made  through  the  vaginal  wall  about  one-half- inch  back  of  the  external  os.  The 
vaginal  waU  is  then  stripped  back  to  the  peritoneal  attachments  m  front  and  behind. 

Treatment  of  Cancer  of  the  Body  of  the  Uterus.— It  is  encouraging 
to  turn  from  the  depressing  picture  of  cancer  of  the  cervLX  to  cancer 


680 


CARCIXOMA  OF  THE   UTERUS 


l^:af telt e"*""^'  ^"'"^  ''^  ^"  =-"*-  P™^P-*  "<  cure  from 

tlTof  7-  ^  '"^'"'^  °*  ''™<*f  "f  tbe  cervix.    Kelh-  also  noted 

tha    ri.s  percentage  of  operative  mortality  is  less  in  cancer-of  the  bodv 
ot  the  uterus  than  m  that  of  the  cervix,  the  ratio  being  7  to  16         * 


Fig.  450 


Vaginal  hystereetomv.     Sten  2      A  «;it    i;„^„ 

va^™lTr™bdomi';,Tr  t1  T'f'^  "!,  ™"P'^*^  hysterectomy,  either 
dSl  I^stettomy.         "  '"'""  '°^^  "°*  d"^"  fr°-  "-'  °f  the 


OPERATIVE  TREATMENT 


681 


Technic  of  Vaginal  Hysterectomy. — With  the  patient  in  the  Hthotomy 
position  and  the  field  of  operation  prepared  in  the  usual  manner,  the 
following  steps  are  taken  in  removing  the  uterus  per  vaginam. 


Vaginal  hysterectomy.     Step  3.     The  Kgated  structures  are  severed  between  the  ligature  and  the 
cervix.     The  Hgatures  are  not  cut. 


Step  1. — The  cervix  is  exposed  by  a  weighted  speculum  and  two 
lateral  retractors. 

Step  2. — A  preliminary  curettage  is  followed  by  swabbing  the  uterus 
with  tincture  of  iodine  or  full  strength  of  formalin. 


682 


CARCIXOMA  OF  THE   UTERUS 


Step  3. — Both  lips  of  the  cervix  are  grasped  with  a  heavy  tenacuUim 
forceps,  on  which  firm  traction  is  made. 

Step  4. — A  circular  incision  is  made  about  the  cervix  three-quarters 
of  an  inch  above  the  external  os.  This  incision  is  made  through  the 
vasrinal  mucosa  onlv. 


Fig.  452 


Vaginal  hj-sterectomy.    Step  4.    The  cul-de-sac  of  Douglas  is  incised  transversely  and  the  peritoneum 
stitched  to  the  free  margin  of  the  vaginal  wall  with  interrupted  sutures  of  catgut. 

Step  5. — ^Yith  a  bit  of  sterUe  gauze  wrapped  about  the  forefinger, 
the  vaginal  mucosa  is  stripped  upward  from  the  ce^^•ix  to  a  point  in 
front  marked  by  the  vesico-uterine  fold  of  peritoneum,  behind 'by  the 
recto-uterine  fold  of  peritonetim,  and  laterally  by  the  base  of  the 
broad    ligaments. 

Step  6. — Grasping  the  fold  of  peritoneum  in  front  of  the  cervix 
with  tissue  forceps,  an  opening  is  made  into  it  by  scissors  and  enlarged 


OPERATIVE  TREATMENT 


683 


laterally  by  spreading  with  the  fingers.  The  peritoneum  is  then 
stitched  to  the  vaginal  wall  in  front  of  the  cervix  by  passing  four  or 
more  interrupted  plain  catgut  sutures  at  intervals  of  about  one-half 
inch. 


Fig.  453 


Vaginal  hysterectomy.  Step  5.  The  cervix  is  turned  downward  and  a  transverse  incision  is  made 
through  the  peritoneal  fold  between  the  bladder  and  uterus.  The  peritoneum  is  stitched  to  the  anterior 
vaginal  flap. 


Step  7.- — A  similar  process  is  carried  out  behind  the  cervix  after 
pulling  the  cervix  dow^nward  and  sharply  forward. 

Step  8. — Ligatures  are  now  passed  through  the  base  of  the  broad 
ligaments  on  either  side  of  the  uterus.  The  author  prefers  to  use  heavy 
linen  sutures  passed  by  a  pedicle  needle.     The  first  suture  is  passed 


684 


CARCINOMA  OF  THE   UTERUS 


close  to  the  supravaginal  portion  of  the  cervix  and  should  embrace 
the  uterine  artery.  A  second  ligature  of  No.  2  plain  catgut  may  be 
passed  at  this  point  to  still  further  secure  the  uterine  artery.  Having 
tied  the  ligatures,  the  ligated  tissues  are  severed  with  scissors  close  to 
the  cervix.  These  and  all  other  ligatures  are  left  long  and  are  grasped 
by  artery  forceps. 

Fig.  454 


Vaginal  hysterectomy.  Step  6.  Additional  ligatures  are  passed  through  the  broad  ligament  on 
either  side  and  the  tissues  severed  between  the  ligatures  and  the  uterus.  Two  ligatures  should  be 
placed  about  either  uterine  artery. 


_  Step  9.— The  cervix  is  then  drawn  forcibly  to  the  opposite  side  and 
similar  ligatures  are  passed  about  the  base  of  the  broad  ligament  and 
the  ligated  structures  severed. 


OPERATIVE   TREATMENT  685 

Step  10. — Similar  ligatures  are  next  passed  higher  up  on  the  broad 
ligament,  alternating  from  side  to  side  according  to  the  accessibility 
of  the  parts.     As  the  ligatures  are  tied,  the  ligated  structures  are  cut 

Fig.  455 


Vaginal  hysterectomy.  Step  7.  Final  ligatures  are  placed  about  the  tubes  and  ovarian  ligaments. 
These  structures  are  severed  from  the  uterus  between  the  hgatures  and  the  uterus.  If  desired  to 
remove  the  appendages,  they  are  drawn  out  together  with  the  uterus  and  a  ligature  is  placed  about 
the  infundibulopehac  Ugament. 

from  the  side  of  the  uterus  and  the  ends  of  the  ligatures  secured  by 
artery  forceps  hanging  outside  the  vagina. 

Step  11. — The  round  ligaments  are  ligated  and  severed  close  to  the 
uterus  on  either  side. 


686 


CARCIXOMA   OF   THE    UTERUS 


Step  12. — If  the  tubes  and  ovaries  are  to  be  removed,  a  ligature  is 
passed  about  the  tubes  and  ovarian  h2:aments  on  either  side  when  thev 


Fig.  4o8 


Vaginal  hysterectomy.  Step  8.  The  ligatures  are  all  dia.vni  out  of  the  vault  of  the  vagina  and  are 
anchored  by  catgut  at  either  side  of  the  opening.  In  this  manner  all  ligatures  are  deUvered  within 
the  vagina,  and  the  vaginal  walls  are  well  supported  by  the  broad  ligaments  and  round'  hgaments. 
The  opening  in  the  vault  of  the  vagina  is  then  closed  with  catgut,  or  if  thought  advisable,  a  strip  of 
gauze  can  be  inserted  for  drainage. 


are  severed  from  the  uterus.  If  the  tubes  and  ovaries  are  to  be  removed, 
together  with  the  uterus,  the  last  ligature  is  passed  about  the  infundibulo- 


OPERATIVE  TREATMENT  687 

pelvic  ligament  and  the  structures  severed  between  the  ligature  and 
the  ovary  and  tube.  The  uterus  is  now  freed  of  all  attachments  and 
is  w^ithdrawn  through  the  vagina. 


Fig.  457 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.  Step  1.  After  stripping  the  vaginal' 'wall 
from  the  cervix  and  opening  into  the  peritoneal  cavity  in  front  and  behind,  the  anterior  wall  of  the 
cervix  and  body  of  the  uterus  are  split  with  scissors  from  below  upward. 


688  CARCINOMA  OF  THE  UTERUS 

Step  13. — The  stumps  of  the  divided  ligaments  and  appendages 
are  now  drawn  into  the  vault  of  the  vagina  and  anchored  to  the  vaginal 
walls  so  that  all  ligatures  lie  within  the  vagina.    This  is  done  by  passing 

Fig.  458 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.  Step  2.  Either  horn  of  the  uterus  is 
grasped  with  a  tenaculum  and  the  uterus  pulled  forward.  The  index  finger  of  the  left  hand  is  inserted 
back  of  the  uterus  as  a  guide  and  the  posterior  wall  of  the  uterus  is  severed  to  the  internal-  os. 

a  No.  2  plain  catgut  suture  on  a  cutting  needle  through  the  anterior 
vaginal  wall,  then  transfixing  the  stumps  of  the  corresponding  side 
above  the  ligatures  and  passing  out  through  the  posterior  wall  of  the 
vagina.     ^Mien  this  suture  is  tied,  the  stumps  are  securely  pinioned 


OPERATIVE  TREATMENT 


689 


to  the  vault  of  the  vagina.  A  similar  process  is  carried  out  on  the 
opposite  side.  One  or  more  additional  sutures  are  passed  through 
the  vaginal  walls  between  the  points  of  exit  of  the  stumps,  and  in  this 
manner  the  vault  of  the  vagina  is  completely  closed.  The  ligatures 
are  then  cut  close  and  the  vagina  is  packed  with  iodoform  gauze. 


Fig,  459 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.     Step  3.     The  posterior  wall  of  the  cervix  is 
severed  in  the  median  line  from  below  upward. 


Step  14. — When  drainage  is  required  a  strip  of  iodoform  gauze  may 
be  carried  into  the  pelvis  between  the  anchored  stumps.    This  should 
be  done  if  there  is  danger  of  hemorrhage  or  infection. 
44 


690 


CARCINOMA  OF  THE   UTERUS 


Variations  in  Technic. — It  may  become  necessary  to  vary  the  above 
technic  because  of  existing  complications.  If  the  uterus  is  large  it 
may  be  found  advisable  to  bisect  the  uterus  and  remove  either  half 
separately  as  illustrated  in  Figs.  459  to  462.    The  author's  preference 


Fig.  460 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.     Step  4.     The  uterus  is  completelj'  bisected 
and  traction  is  made  outward  upon  either  half  of  the  uterus. 


would  be  for  abdominal  hysterectomy  in  such  cases.  Again,  it  may  be 
found  easier  to  deliver  the  body  of  the  uterus  through  the  anterior 
incision  and  ligate  the  lateral  structures  from  above  downward  as 
shown  in  Figs.  461  and  462. 


OPERATIVE  TREATMENT 


691 


The  operator  should  not  restrict  himself  to  any  fixed  rule  of  pro- 
cedure, but  should  adapt  himself  to  the  conditions  as  they  arise.  Occa- 
sionally the  author  has  found  it  necessary  to  open  the  abdomen  in  the 


Fig.  461 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.  Step  5.  The  structures  lateral  to  the  uterus 
are  Ugated  and  severed  from  the  uterus  from  above  downward.  The  appendages  may  or  may  not  be 
removed. 

course  of  a  vaginal  hysterectomy  for  the  purpose  of  severing  the  upper 
attachments  which  could  not  be  reached  from  below  because  of  the 
large  size  of  the  uterus  and  the  presence  of  adhesions  and  diseased 
appendages. 


692 


CARCIXOMA  OF  THE   UTERUS 


Afier-treaiment. — The  gauze  pack  in  the  vagina  is  removed  at  the 
end  of  twenty-four  hours.  Vaginal  antiseptic  douches  are  given  daily 
after  the  fourth  day  until  all  discharges  have  ceased.  The  patient  may 
be  allowed  to  walk  about  after  the  fourteenth  day. 


Fig.  462 


Bisecting  the  uterus  to  facilitate  vaginal  hysterectomy.  Step  6.  After  ligating  and  severing  all 
attachments  to  the  uterus,  the  stumps  are  drawn  into  the  vault  of  the  vagina  and  anchored  to  the 
vaginal  walls. 


Endothelioma. — By  endothelioma  is  meant  a  malignant  new-forma- 
tion arising  from  the  endothelium  of  blood  and  lymphatic  vessels  and 


SARCOMA  OF  THE  UTERUS  693 

from  serous  surfaces.  Endothelioma  appears  at  any  time  in  life.  The 
earliest  reported  case  is  that  of  Braetz,  at  eighteen  years  of  age. 

Such  growths  differ  from  carcinoma  and  sarcoma  not  only  in  their 
histogenesis,  but  also  in  their  histological  structure. 

In  their  gross  appearance  there  is  nothing  distinctive.  Under  the 
microscope  the  lumina  of  blood  and  lymph  spaces  are  seen  to  be  dis- 
tended ^vith  rapidly  proliferating  endothelium.  The  neighboring  con- 
nective tissue  and  bloodvessels  may  be  invaded.  The  individual  cells 
assume  a  variety  of  shapes  and  are  not  always  recognized  as  endothe- 
lial in  origin.  The  flat  cells  become  irregular  in  outline  and  swollen 
and  the  nuclei  take  a  deep  stain.  It  may  be  possible  to  identify  these 
cells  by  tracing  them  to  their  origin  in  the  walls  of  the  vessels  when 
they  are  not  so  changed  in  structure. 

It  is  puzzling  to  differentiate  between  a  carcinoma  invading  the 
lymph  spaces  and  an  endothelioma  arising  from  the  lymph  spaces. 
In  lymphatic  carcinoma  the  appearance  is  that  of  veins  of  marble  in 
the  stroma. 

SARCOMA  OF  THE  UTERUS 

From  the  older  literature  we  are  led  to  believe  that  sarcoma  of  the 
uterus  is  an  extremely  rare  condition.  Roger  Williams  and  Gurlt 
reported  10  sarcomata  in  6764  tumors  of  the  uterus.  Doubtless  many 
sarcomata  were  regarded  as  carcinomata  through  failure  to  make  a 
microscopic  examination.  Some  were  regarded  as  fibroids  and  were 
spoken  of  as  recurrent  fibroids.  The  growing  frequency  of  reported 
cases  is  evidence  of  the  discrepancies  in  previous  reports. 

Whitridge  ^Yilliams,  in  his  Contrihution  to  the  Histology  and  Histo- 
genesis of  Sarcoma  of  the  Uterus,  reported  11-i  uterine  sarcomata  in  the 
literature.  The  proportion  of  sarcoma  to  carcinoma  of  the  uterus  is 
said  to  be  1  to  40. 

The  frequency  with  which  sarcoma  of  the  uterus  occurs  is  a  some- 
what debatable  question.  This  is  accounted  for  by  the  fact  that  this 
tumor  is  frequenth'  mistaken  for  cancer  and  for  fibroma,  von  Gurlt 
found  in  2649  cases  of  uterine  tumors,  1571  cancers,  883  fibroids,  and 
2  sarcomata.  Roger  Williams  found  8  sarcomata  in  41 15  uterine  tumors. 
Geisler,  in  2369  cases,  found  8  sarcomata,  as  compared  with  405  cancers 
of  the  uterus  and  288  fibroids.  This  gives  a  ratio  of  1  sarcoma  to  50 
cancers.  Veit  found  in  42,395  cases,  1493  cancers  of  the  uterus  and 
40  sarcomata  with  2  cases  classified  as  doubtfid;  this  gives  a  ratio  of 
1  sarcoma  to  37.1  cancers. 

Etiology. — Nothing  is  known  of  the  essential  cause  of  sarcoma. 
What  has  been  said  of  Cohnheim's  theory  receives  no  confirmation 
in  sarcoma.  Inflammatory  lesions  and  trauma  seem  to  bear  no  causal 
relation,  nor  does  childbearing.  Fully  two-thirds  of  the  cases  are 
found  in  women  who  either  have  not  borne  children  or  have  given 
birth  to  less  than  the  average  number.  We  find  no  age  exempt,  from 
infancy  to  the  postclimacteric  period.    A  case  has  been  lately  reported 


694 


SARCOMA  OF  THE  UTERUS 


in  which  a  hysterectomy  was  performed  at  three  years  of  age.  Pick 
reports  a  case  at  two  years  of  age.  Hollander's  case  was  seven  months 
old  when  the  disease  was  first  discovered.  The  oldest  case  recorded 
was  seventy  years.  Gusserow  reports  73  cases,  of  which  4  were  under 
twenty-nine  years  of  age;  15  were  from  thirty  to  forty  years;  28  from 
forty  to  fifty;  18  from  fifty  to  sixty,  and  3  were  over  sixty  years  of  age. 

Fig.  463 


Fibrosarcoma  of  the  corpus  uteri.  A  firm,  rapidly  growing  tumor  the  size  of  a  child's  head  pro- 
trudes from  the  vulva.  Its  attachment  may  be  traced  by  a  pedicle  through  the  cervix  to  the  fundus 
of  the  uterus.  The  tumor  is  not  to  be  mistaken  for  inversion  or  prolapsus  uteri,  though  either  condi- 
tion may  be  caused  by  the  traction  of  the  tumor. 


Anatomical  Diagnosis. — As  in  carcinoma  of  the  uterus,  sarcoma  is 
found  in  the  vaginal  portion  of  the  cervix,  in  the  cervical  canal,  and 
in  the  body  of  the  uterus. 

1.  Sarcoma  of  the  Vaginal  Portion  of  the  Cervix. — ^This  is  an  uncommon 
location  for  sarcoma.  To  the  naked  eye  there  is  no  way  of  distinguish- 
ing this  growth  from  carcinoma.  There  are  the  cauliflower  and  the 
infiltrating  forms,  resembling  those  found  in  carcinoma  of  the  vaginal 
portion. 

2.  Sarcoma  of  the  Cervix. — Sarcoma  of  the  cervix  is  distinctive  when 
assuming,  as  it  usually  does,  a  grape-like  form  (sarcoma  botryoides). 
The  mass  protrudes  from  the  external  os  and  hangs  into  the  vagina 


ANATOMICAL  DIAGNOSIS 


695 


as  transparent  vesicles,  appearing  not  unlike  a  vesicular  mole.  This 
form  is  more  often  found  in  childhood,  but  may  appear  in  old  age. 
Pfannenstiel  found  50  per  cent,  in  nulliparae.  A  similar  growth  is 
sometimes  seen  in  the  body  of  the  uterus,  due  to  edema  or  myxomatous 
degeneration  of  the  growth.  Carcinoma  of  the  cervix  never  assumes 
this  vesicular  form. 

Fig.  464 


Sarcoma  of  the  cervix.     A  tumor  the  size  of  a  man's  fist  grew   from   the  posterior  lip  of  the  cer\'ix. 
It  was  of  rapid  growth,  nodular,  quite  vascular,  and  friable.      It  was  a  mixed-cell  sarcoma. 


Various  heterotopic  structures  are  frequently  mixed  with  the  sarco- 
matous tissue;  these  are  cartilage,  bone,  epithelial  elements,  and  mucous 
tissue. 

Sarcoma  of  the  cervix  may  form  a  diffuse  infiltration  of  the  cervical 
tissue  or  protrude  from  the  surface  as  a  tuberculous,  polypoid,  or  cauli- 
flower   growth. 

3,  Sarcoma  of  the  Body  of  the  Uterus. — Sarcoma  of  the  body  of  the 
uterus  arises  from  any  of  the  mesoblastic  structures.  Very  commonly 
the  growth  is  a  malignant  transformation  of  a  preexisting  fibroid  tumor. 

(a)  Sarcoma  of  the  suhmucosa  may  take  the  form  of  a  diffuse  infil- 
tration or  of  a  papillary,  polypoid,  or  nodular  growth  projecting  from 
the  surface.    The  surface  of  these  growths  is  never  shaggy  as  in  carci- 


696  SARCOMA  OF  THE   UTERUS 

noma.  The  color  varies  from  pale  gray  to  dark  red.  Their  consistency 
is  soft  and  often  friable.  The  growth  rarel>-  begins  as  a  diffuse  involve- 
ment of  the  mucosa,  but  rather  as  a  circumscribed  lesion  extending 
by  continuity  of  surface  and  by  metastasis. 

(b) '  Sarcoma  of  the  wall  of  the  uterus  generally  arises  from  submucous 
or  interstitial  fibroids.  The  fibrous  structure  of  the  tumor  gives  place 
to  a  homogeneous  substance  of  soft  consistency,  varying  in  color  from 
pale  gray  to  dark  red.  The  growth  is  rapid  as  compared  to  that  of  a 
fibroid.  Recurrent  fibroids  were  recognized  in  the  days  when  the 
microscope  was  little  used.  They  are  now  regarded  as  fibrosar- 
comata. 

Sarcoma  spreads  through  the  uterine  wall  to  the  peritoneum  and  to 
the  abdominal  and  pelvic  viscera.  Metastasis  to  neighboring  organs 
and  to  lymphatic  glands  is  unusual.  The  point  of  earliest  attack  is 
the  lung.  The  ovary  is  the  seat  of  secondary  invasion  more  often  in 
sarcoma  than  in  carcinoma. 

Microscopic  Diagnosis. — As  elsewhere  in  the  body,  sarcoma  is 
classified  as  round  cell,  spindle  cell,  or  giant  cell.  There  is  frequently 
a  mixture  of  these  cells. 

1.  Round-cell  Sarcoma. — Round-cell  sarcoma  is  composed  of  large  or 
small  round  cells  ha^'ing  a  large  nucleus  and  a  limited  rim  of  proto- 
plasm. The  diameters  of  the  cells  vary  from  4  to  15  mm.  There 
is  a  variable  amount  of  chromatin  and  an  abundance  of  karyokinetic 
figures.  Numerous  newly  formed  bloodvessels  are  seen.  The  sarcoma 
cells  border  directly  upon  blood-spaces. 

2.  Spindle-cell  Sarcoma. — Spindle-cell  sarcoma  is  composed  of  large 
or  small  elongated  cells,  arranged  in  bundles  and  bands.  On  section 
they  appear  in  various  forms  from  round  to  spindle.  Two  or  more 
nuclei  are  observed.     The  amount  of  chromatin  varies  greatly. 

3.  Giant-cell  Sarcoma. — Giant-cell  sarcoma  is  a  rare  finding  in  the 
uterus.  These  cells  may  be  SO  mm.  in  diameter.  They  are  poly- 
nuclear,  and  are  rich  in  chromatin  and  mytotic  figures.  The  nuclei 
vary  in  shape  and  in  staining  qualities.     Vacuoles  may  be  present. 

In  all  the  above  forms  the  fibrillar  network  may  be  so  scanty  that  it 
escapes  notice,  or  so  abundant  that  the  name  fibrosarcoma  is  suggested. 
As  a  rule,  the  connective-tissue  framework  is  distributed  uniformly 
between  the  cells,  but  nests  oi  cells  may  be  surrounded  by  connective 
tissue,  giving  the  appearance  of  cancer  nests  (alveolar  sarcoma) .  Newly 
formed  bloodvessels  are  prominent  features  of  sarcoma,  and  may  be 
sufficiently  abundant  to  give  to  the  tumor  the  name  angiosarcoma. 

The  intimate  association  of  the  blood-channels  with  the  surrounding 
sarcoma  cells  is  characteristic.  No  sharp  distinction  can  be  made 
between  the  three  microscopic  forms.  A  mixture  of  two  or  three 
varieties  of  cells  is  the  rule. 

Secondary  changes  in  sarcoma  tissue  are  of  common  occurrence,  though 
not  so  frequent  as  in  carcinoma,  for  the  reason  that  sarcoma  cells  are 
more  directly  supplied  with  blood.  Degenerative  changes  ordinarily 
begin  in  the  centre  of  the  sarcoma.    The  cells  at  the  periphery  do  not 


PROGNOSIS  697 

usually  suffer  change.  The  degenerative  forms  commonly  seen  are  the 
hemorrhagic,  hyaline,  and  fatty. 

Mixed  Tumors. — The  tendency  of  sarcoma  cells  to  assume  the  mature 
type  accounts  for  the  frequency  of  the  so-called  myosarcoma  of  the 
uterus.  Myxosarcoma  is  a  mjocomatous  degeneration  of  the  connec- 
tive-tissue stroma.  Enchondrosarcoma,  carcinosarcoma,  and  melano- 
sarcoma  are  of  extremely  rare  occurrence. 

Clinical  Diagnosis. — All  that  has  been  said  of  the  clinical  diagnosis 
of  carcinoma  of  the  uterus  applies  to  sarcoma.  The  clinical  manifesta- 
tions and  physical  findings  do  not  materially  differ  from  carcinoma. 
The  differential  diagnosis  of  carcinoma  from  sarcoma  must  depend 
upon  the  microscope. 

The  early  recognition  of  sarcomatous  degeneration  of  a  fibromyoma  is  of 
the  utmost  importance.  When  a  fibromyoma  of  the  uterus  undergoes 
malignant  changes  it  takes  on  rapid  growth,  becomes  softer  in  con- 
sistency, more  pain  is  experienced  in  the  region  of  the  tumor,  cachexia 
rapidly  develops,  ascites  may  make  its  appearance,  and  metastatic 
growths  may  arise  in  the  lungs  and  elsewhere.  If  the  tumor  is  interstitial 
or  submucous,  the  hemorrhages  will  be  greater.  When  a  fibroid  takes 
on  a  rapid  growth,  particularly  if  near  the  time  of  the  menopause,  no 
time  should  be  lost  in  removing  the  growth.  When  after  removal  of 
a  fibroid  the-  growth  returns,  it  is  suggestive  of  sarcoma. 

The  length  of  time  a  sarcoma  may  exist  before  destroying  life  is 
variable,  and  has  been  observed  from  two  months  to  five  years.  The 
average  time  is  estimated  at  two  years. 

Because  of  the  frequency  with  which  a  sarcomatous  degeneration 
of  a  fibroid  tumor  of  the  uterus  is  overlooked,  the  following  suggestions 
as  to  the  clinical  recognition  of  sarcomatous  degeneration  of  uterine 
fibroids  is  here  presented. 

Suspicion,  sufficient  to  justify  operative  interference,  is  aroused 
when: 

1.  The  tumor  takes  on  a  rapid  growth  in  the  absence  of  pregnancy. 

2.  The  tumor  becomes  soft. 

3.  The  growth  becomes  manifest  near  the  time  of  the  climacterium. 

4.  The  tumor  occasions  bleeding  in  advanced  age. 

5.  Ascites  and  loss  of  flesh  with  cachexia  accompany  the  growth. 

6.  There  is  recurrence  of  a  fibroid  that  was  once  removed. 
Prognosis. — As  with  all  malignant  tumors  the  prognosis  in  sarcoma 

of  the  uterus  is  uncertain,  no  matter  how  early  the  growth  is  discovered 
and  removed. 

We  cannot  rely  upon  the  statistics  of  the  older  writers  because  of 
the  frequent  discrepancies  in  diagnosis.  Veit  asserts  that  the  average 
length  of  life  in  sarcoma  of  the  uterus  is  two  to  three  years.  Cases 
are  reported  in  which  life  was  prolonged  over  a  period  of  ten  years. 

Metastasis  is  not  as  common  as  in  carcinoma.  Gessner  records  33 
cases  in  which  metastasis  occurred  but  nine  times.  The  lungs,  liver, 
intestine,  omentum,  kidney,  and  pleura  are  attacked  with  greatest 
frequency  and  in  the  order  named. 


698  SARCOMA  OF  THE   UTERUS 

AMien  death  occurred  without  operation,  Gessner  in  99  cases  found 
the  following  causes  for  death: 

Cachexia  and  metastasis 57 

Septic  diseases 28 

Nephritis 5 

Ileus 4 

Intercurrent  diseases 3 

Uremia 1 

Lung  emboUsm 1 

In  general,  we  may  say  that  the  prognosis  of  sarcoma  is  no  better 
than  that  of  carcinoma  of  the  uterus. 

Treatment. — So  uncertain  is  the  early  recognition  of  sarcoma  of 
the  uterus,  and  so  speedy  does  it  become  inoperable  through  metastatic 
invasion,  that  the  only  safe  procedure  is  to  operate  on  a  well-grounded 
suspicion.  The  suspicion  should  be  verified  when  possible  by  the 
microscopic  examination  of  excised  pieces  or  scrapings. 

In  operating  fibroid  tumors  of  the  uterus,  they  should  be  incised  after 
removal,  and  if  the  bands  and  whirls  are  found  to  be  replaced  by  a 
grayish  semitranslucent  mass,  the  entire  uterus  and  adnexse  should  be 
removed. 

The  technic  of  operation  does  not  differ  essentially  from  that  of  the 
classical  abdominal  hysterectomy.  Special  precautions  must  be  taken 
to  prevent  troublesome  hemorrhage. 


CHAPTER  XXIX 


TIBIORS  OF  THE  PELVIC  LIGAMENTS,  FALLOPIAN 
TUBES,  AND   OVARIES 


Tumors  of  the  Pelvic  Ligaments 
Tumors  of  the  Broad  Ligaments 
Tumors  of  the  Ovarian  Ligaments 
Tumors  of  the  Round  ligaments 
Treatment 
Tumors  of  the  Fallopian  Tubes 
Papilloma 
Polj'ps 

Myoma  and  Fibroma 
Dermoid  Cysts 
Lipoma 
FibromjTcoma    Cystoma    of    the 

Fimbriae 
Sarcoma 
Carcinoma 

Cystic     New-formations     of    the 
Fallopian  Tubes 
Hydatids  of  ]Morgagni 
New-formations  of  the  Ovary 
Simple  Cysts 
Follicular 

Corpus  Luteum  Cysts 
Tuboovarian  Cj'sts 


Cysts  of  the  Ovaries 
Carcinoma 
Dermoid  Cj^sts 

Connective     Tissue     New-forma- 
tions 

Fibroma 

]Mj^oma 

Myxoma 

Enchondroma  and  Ostioma 

Angioma  and  Ljanphangioma 
Sarcoma 
Endothelioma 
Parovarian  Cysts 
Ovariotomj'' 

Vaginal 

Abdominal 

Malignancy    of    Ovarian 
Tumors 
Treatment    of    Ovarian    Tumors 
Complicating      Pregnancy, 
Labor,  and  the  Puerperium 
Postoperative  Complications 

INIortality 
Conservative  Operations 


TUMORS  OF  THE  PELVIC  LIGAMENTS 

1.  Tumors  of  the  Broad  Ligaments. — Primary  tumors  of  the  broad 
ligaments  are  rare;  they  are  classified  as  benign  and  malignant. 

(a) .  Benign  tumors  of  the  broad  ligament  are  fibromata  in  nearly  all 
instances.  They  develop  from  the  unstriped  muscle  fiber  between 
the  peritoneal  folds  of  the  broad  ligaments.  They  are  rarely  large, 
but  are  known  to  extend  upward  to  the  umbilicus  and  downward  to 
the  pelvic  floor  and  vaginal  walls.  Lipomata  of  the  broad  ligaments 
are  reported,  though  they  are  very  rare. 

(6)  Malignant  tumors  of  the  broad  ligaments  are  secondary  to 
primary  grow^ths  in  the  neighboring  organs,  notably  the  uterus,  more 
rarely  the  Fallopian  tubes  and  ovaries.  Cancer  and  sarcoma  are  the 
two  varieties  found,  the  former  being  by  far  the  more  common. 

2.  Tumors  of  the  Ovarian  Ligaments. — The  most  common  tumor 
of  the  ovarian  ligament  is  a  fibroma.  They  are  rare,  and  seldom  grow 
larger  than  a  hen's  egg.     Cancer  and  sarcoma  have  been  reported. 


700       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

3.  Tumors  of  the  Round  Ligament. — Fibroma,  carcinoma,  and 
sarcoma  are  found  in  the  round  ligaments;  the  former  are  the  most 
common,  though  all  are  rare. 

Fibroid  tumors  of  the  round  ligament  may  arise  from  the  pelvic 
portion  of  the  ligament  or  from  the  extraperitoneal  portion.  In  the 
latter  case  they  are  located  in  the  inguinal  canal  or  labium  majus. 
They  do  not  differ  in  their  microscopic  or  macroscopic  features  from 
fibroids  of  the  uterus. 

Treatment  of  Tumors  of  the  Pelvic  Ligaments. — All  benign  tumors 
should  be  enucleated  as  soon  as  recognized.  Malignant  tumors  rarely 
permit  of  operative  interference. 


TUMORS  OF  THE  FALLOPIAN  TUBES 

New-formations  of  the  Fallopian  tubes  are  of  rare  occurrence. 
Those  described  are  papilloma,  polyp,  myoma,  fibroma,  dermoid 
cyst,  lipoma,  fibromyxoma,  cystoma,  sarcoma,  carcinoma,  endothe- 
lioma, syncytioma  malignum. 

Fig.  465 


-T-i 


.O.i 


Fibromyxoma  fimbriarum  tubas  cystosum.  U,  uterus;  Td,  right  tube;  Od,  right  ovary;  Ts,  left 
ovary;  Its,  left  infundibulum  of  the  tube;  Os,  left  ovary;  Til,  pedtmculated  tumor;  T2II,  pedunculated 
tumor;  T3,  secondary  pedunculated  tumor;  Ov,  calcareous  body  resembling  an  ovary;  X,  cyst  con- 
taining dark  yellow  fluid;  y,  gelatinous  tissue  without  cavities;  I,  blood-cysts  with  blood  detritus; 
II,  blood-cyst  with  fresh  blood;  III,  soft  myxomatous  tumor;  IV,  soft  myxomatous  tumor.     (Martin.) 

Papilloma. — Papilloma  arises  from  the  endosalpinx.  Sanger  was 
able  to  collect  only  six  cases  in  the  literature.  Simple  papilloma  takes 
the  form  of  a  villous  or  cauliflower  growth  which  may  distend  the 
tube.    The  villosities  may  adhere  and  lock   in  cystic  spaces.     The 


TUMORS  OF  THE  FALLOPIAN  TUBES  701 

growth  is  histologically  constructed  of  connective  tissue,  covered  by 
a  single  layer  of  columnar  epithelium,  having  no  disposition  to  invade 
the  connective  tissue,  as  is  the  case  in  malignant  papilloma.  Metastasis 
does  not  occur.  It  has  been  suggested  by  Doran  that  benign  papillary 
growths  are  of  inflammatory  origin.  He  bases  his  opinion  on  a  certain 
definite  inflammatory  reaction  seen  to  accompany  the  growth.  He 
believes  gonorrhea  to  be  a  potent  factor. 

Polyps. — Polyps  of  the  tube  are  virtually  inflammatory  lesions. 
They  are  rarely  found. 

Myoma  and  Fibroma. — ]\Iyoma  and  fibroma  of  the  tube  are  not  to 
be  mistaken  for  the  nodular  swellings  of  salpingitis  isthmica  nodosa. 
Five  cases  are  reported  by  Sanger.  Bland  Sutton  reported  one  the 
size  of  an  orange,  v.  Recklinghausen  reported  an  adenomyoma  of  the 
tube  arising  from  the  duct  of  Miiller. 

Dermoid  Cysts. — Dermoid  cysts  of  the  tube  are  described  by  Pozzi 
and  Richie. 

Lipoma. — Lipoma  is  not  of  such  unusual  occurrence  in  the  tube.  It 
is  usually  located  between  the  two  layers  of  the  mesosalpinx,  and  has 
been  known  to  attain  the  size  of  a  hen's  egg. 

Fibromyxoma  Cystoma  of  the  Fimbriae. — Fibromyxoma  cystoma  of 
the  fimbriae  was  described  by  Sanger  (Fig.  465).  There  were  three 
tumors  connected  by  fimbriae  to  a  normal  tube.  They  consisted  of 
fibrous  and  myxomatous  tissue. 

Sarcoma. — Sarcoma  of  the  tube  has  a  papillary  structure  that  cannot 
be  distinguished  from  benign  papilloma  or  carcinoma  by  the  naked 
eye.    But  five  cases  are  recorded. 

Carcinoma. — Carcinoma  of  the  Fallopian  tube  may  be  primary  or 
secondary.  Secondary  cancer  of  the  tube  is  not  rare  but  primary  cancer 
of  the  tube  is  exceedingly  rare.  As  a  primary  growth  it  is  rarely  bilateral. 
The  growth  is  usually  papillary,  rarely  alveolar.  The  development  is 
rapid  and  metastasis  is  early.  The  naked-eye  appearance  of  the  tube 
is  not  unlike  that  of  a  hydrosalpinx.  The  suggestion  is  pertinent  to 
bisect  all  suspicious  tubes  removed  in  the  cancer-bearing  age,  and  if  a 
papilloma  is  found,  to  perform  a  radical  removal  of  not  only  the  tube 
but  the  uterus,  opposite  tube  and  ovaries. 

An  excellent  monograph  on  the  subject  by  Norris  appears  in  the 
Journal  of  Surgery,  Gynecology,  and  Obstetrics,  March  1909. 

Orthmann  was  the  first  to  describe  primary  carcinoma  of  the  tube. 
Like  other  new  formations  of  the  tube,  carcinoma  assumes  a  papillary 
form,  and  in  its  histological  structure  is  not  unlike  papillary  adenoma 
of  the  ovary  and  malignant  adenoma  of  the  uterus.  Secondary  carci- 
noma of  the  tube  resembles  the  primary  growth,  and  is  usually  an 
extension  from  a  similar  growth  in  the  uterus.  One-third  of  the  primary 
carcinomata  of  the  ovary  extend  to  the  tube.  It  has  been  repeatedly 
observed  that  inflammatory  lesions  of  the  tubes  serve  as  forerunners 
of  carcinoma. 

Le  Count  says:  "It  is  especially  concerning  tumors  of  the  Fallopian 
tube  that  confusion  has  arisen;  there  has  been  quite  a  general  failure 


702       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

to  recognize  that  a  diffuse  hyperplastic  inflammation  is  possible — a 
process  that  is  strictly  analogous  to  the  polypous  hyperplasia  of  other 
mucous  surfaces — and  that  in  certain  typical  examples  it  is  as  distinct 
from  tumor  growth  as  gastritis  proliferans  is  from  carcinoma  of  the 
stomach."  He  believes  it  is  fully  demonstrated  that  there  exists  an 
imperceptible  transition  of  hyperplastic  processes  of  the  tubal  mucosa 
into  those  of  true  tumor  growth,  and  that  these  may  terminate  in  the 
production  of  benign  tumors  and  then  into  a  malignant  new-formation. 

Fig.  466 


Primary  carciaoma  of  the  tube.  (Natural  size.)  a  is  the  proximal  end  of  the  tube  and  b  the  occluded 
fimbriated  extremity.  Near  the  uterus  the  tube  is  nearly  normal  in  size,  but  rapidly  enlarges  until 
near  the  fimbriated  extremity  it  is  3  cm.  in  diameter.  At  e  are  two  subperitoneal  cysts.  The  ovary, 
c,  contains  a  small  cyst  with  dark-colored  walls.  Attached  to  the  under  surface  of  the  ovary  are 
several  adhesions.     (Hurdon.) 

We  find  carcinoma  of  the  tubes  occurring  about  the  time  of  the 
menopause — a  time  when  inflammatory  lesions  are  less  frequent. 

Sanger-Barth  observed  a  direct  malignant  degeneration  of  the  tubal 
mucosa.  Doran  and  Fearne  observed  a  malignant  transformation  in 
a  benign  papilloma. 

Carcinoma  of  the  Fallopian  tube  is  commonly  unilateral.  Zange- 
meister  reported  three  cases  of  primary  carcinoma  of  the  tube,  all  of 
which  were  bilateral.  All  six  tubes  presented  the  external  appearance 
of  sactosalpinx.  The  tube  w^alls  were  thin.  Within  the  tubes  were 
papillary  growths  which,  under  the  microscope,  resembled  adenocarci- 
noma of  the  uterus.  Zangemeister  found  fifty-one  cases  in  the  literature. 
According  to  Sanger-Barth,  it  usually  arises  from  the  middle  and  outer 
portions  of  the  tube. 

In  conformity  with  many  authors  we  will  recognize  two  microscopic 
forms,  the  papillary  and  the  alveolar. 


NEW-FORMATIONS  OF  THE  OVARY  703 

The  papillary  form  consists  of  numerous  papillae,  composed  of  con- 
nective tissue  and  covered  by  columnar  epithelium. 

Alevolar  carcinoma  of  the  tube  shows  a  greater  proliferation  of  the 
epithelium,  and  the  grouping  of  these  epithelial  elements  into  nests. 

Cystic  New  Formations  of  the  Fallopian  Tubes. — Hydatids  of  Morgagni. 
— Hydatids  of  Morgagni  are  transparent  cysts  containing  a  clear, 
watery  fluid.  They  are  found  on  the  peritoneal  covering  of  the  tube 
and  broad  ligament,  either  isolated  or  arranged  in  groups.  The 
fimbriae  of  the  tube  may  distend  with  a  similar  fluid  and  present 
the  appearance  of  cysts  of  Morgagni. 

Cysts  as  large  as  walnuts  have  been  found  in  the  mucosa  of  the 
tube,  and  are  inclusions  of  the  mucous  folds. 

Cysts  of  equal  size  are  found  in  the  musculature.  These  arise  from 
the  ducts  of  Gartner. 

The  following  classification  is  from  Sanger: 

1.  Serous  cysts,  lying  beneath  the  serous  covering  of  the  tube  and 
varying  in  size  to  a  child's  head. 

2.  Lymphangiectasis. 

(a)  Small  cysts  on  the  tube  and  ligament. 

(b)  Winding   canals    or   cysts    located   under    or   within    the 

peritoneum  of  the  tube  and  broad  ligament. 

(c)  Lymphangiectatic  cysts,  large  and  isolated,  located  in  the 

subserosa  of  the  tube  and  in  the  mesosalpinx. 

3.  Hydatids  of  Morgagni  are  to  be  regarded  as  physiological,  and 
are  located  at  the  ends  of  the  fimbrise. 


NEW-FORMATIONS  OF  THE  OVARY 

Simple  Cysts. — Among  simple  cysts  of  the  ovary  will  be  included 
those  cystic  formations  occupying  an  intermediate  position  between 
the  cystic  inflammatory  lesions  and  the  cystic  new-formations. 

1.  Follicular  Cysts. — (See  page  484.) 

2.  Corpus  Luteum  Cysts.- — Corpus  luteum  cysts,  as  the  name  implies, 
arise  from  the  corpus  luteum,  and  hence  are  single  and  are  located  on 
the  periphery  of  the  ovary.  As  compared  with  follicular  cysts,  they 
are  thick-walled.     In  size  they  vary  from  a  bean  to  a  man's  head. 

The  wall  of  the  cyst  presents  the  characteristic  yellow,  corrugated 
appearance  of  the  luteum  cell  layer,  and  external  to  this  is  the  pale, 
fibrous  envelope.  The  contents  of  the  cyst  are  commonly  a  clear,  serous 
fluid;  this  is  occasionally  mixed  with  blood  and  degenerated  cells. 

3.  Tuboovarian  Cysts. — These  have  been  previously  referred  to. 
Rosthorn  gives  the  following  groups  in  explanation  of  the  origin  of 
tuboovarian  cysts: 

Group  I. — 1.  Cases  in  which  a  pyosalpinx  becomes  adherent  to  the 
wall  of  an  ovarian  abscess,  with  subsequent  communication  established 
between  them.  Later  the  formed  elements  of  the  pus  are  absorbed, 
leaving  a  serous  fluid. 


704       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

2.  Adhesions  of  the  paviHon  of  the  tube  to  the  waU  of  a  suppurating 
ovarian  cyst,  with  subsequent  development  of  hydrosalpinx  and  per- 
foration of  the  cyst  into  the  tube. 

3.  Adhesions  of  a  hydrosalpinx  to  a  papillomatous  cyst,  with  sub- 
sequent perforation  of  the  intervening  wall  by  papillary  growths. 

Fir,.  467 


Corpus  luteum  cyst.  Numerous  small  follicular  cj-sts  are  seen  in  the  substance  of  the  ovary.  At 
the  periphery  of  the  ovarj-  is  a  thin-walled  cyst,  double  the  size  of  the  ovary,  and  originating  in  a 
corpus  luteum.     (Specimen  removed  by  Dr.  J.  Clarence  Webster.) 

~  Group  II. — 1.  Cases  in  which  a  hydrosalpinx  becomes  adherent 
to  the  wall  of  a  follicular  cyst,  with  subsequent  perforation  of  the 
septum. 

2.  Cases  in  which  the  fimbriae  of  a  pre\-iously  diseased  tube  are 
caught  in  the  opening  of  a  ruptured  follicle  at  the  moment  of  rupture 
and  become  adherent  to  the  wall  of  the  follicle. 

Anatomical  Diagnosis. — A  tuboovarian  cyst  may  distend  to  the  size 
of  a  child's  head.    The  general  form  is  that  of  a  retort.     The  wall  is 


NEW-FORMATIONS  OF  THE  OVARY 


705 


^'^:'z^s:tj-t:^^''  --  ^^^-  ^^-  the 


Fig.  468 


Fig.  469 


Fig.  470 


Fig.  471 


Figs.  468  to  471.-Four  different  views  of  tuboovarian  cyst. 

a  flinLif" """'  ""^  ^^'/^^'*  resembles  a  hydrosalpinx  on  one  side  and 


706       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

The  tubal  portion  is  lined  with  ciliated  epithelium  and  the  ovarian 
portion,  either  with  a  fibrous  or  granular  surface  layer,  or  with  a  low 
type  of  epithelium.    The  contents  is  clear  serum,  rarely  blood-stained. 

Clinical  Diagnosis. — The  clinical  diagnosis  cannot  be  made  from 
hydrosalpinx.  The  diagnosis  is  only  made  by  a  careful  examination 
of  the  specimen  after  its  removal. 

Tumors  of  the  Ovaries. — Etiology. — Ovarian  tumors  were  found  in 
1.4  per  cent,  of  36,158  cases  in  Martin's  clinic.  The  following  table 
from  Stander  shows  the  relative  frequency  of  various  tumors  of  the 
ovaries : 

Cystadenoma 205  =  69 .  49  per  cent. 

Carcinoma 40  =  13.56  per  cent. 

Embryoma     .            .      .      .    • 26  =  8.81  per  cent. 

Sarcoma 20  =  6 .  78  per  cent. 

Fibroma 4  =  1 .  36  per  cent. 

Referring  to  the  age  at  which  ovarian  tumors  appear,  we  find  Doran 
reporting  a  case  of  sarcoma  of  the  ovary  in  infancy,  and  Romans 
operating  upon  a  tumor  of  the  ovary  at  eighty-two  years  of  age.  The 
following  is  a  table  prepared  by  Olshausen,  in  which  are  given  the 
number  of  tumors  found  and  the  respective  ages  of  the  patients: 

61  under       .      .     ■ 10  years 

490  between 20  and  29  years 

499  between 30  and  39  years 

372  between  .      .  ■ 40  and  49  years 

342  at 50  and  over 

It  will  be  seen  from  the  above  table  that  tumors  of  the  ovary  occur 
with  about  equal  frequency  between  the  ages  of  twenty  and  fifty  years. 

The  social  state  has  no  influence  upon  the  development  of  ovarian 
tumors;  they  occur  with  about  equal  frequency  in  the  single  and 
married.  They  may  be  the  cause  of  sterility,  but  it  is  not  likely  that 
sterility  predisposes  to  their  development. 

While  two  or  more  members  of  the  same  family  have  been  known 
to  be  afflicted  with  ovarian  tumors,  it  is  not  believed  that  heredity 
plays  a  role  in  the  development  of  these  neoplasms.  In  1000  cases 
of  Spencer's,  8.2  per  cent,  were  bilateral,  while  Olshausen  gives  13.7 
per  cent,  in  322  cases. 

Classification. — The  old  classification  of  tumors  of  the  ovary  into 
cystic  and  solid  tumors  was  of  the  greatest  service  when  the  operative 
treatment  was  limited  to  the  tapping  of  fluid;  At  the  present  time, 
when  tumors  of  the  ovary  are  removed  en  masse,  such  a  classification 
does  not  meet  the  requirements. 

Tumors  of  the  ovary  are  classified  as  benign  and  malignant.  Waldeyer 
classifies  them  according  to  their  histology  and  histogenesis  into  epithe- 
lial (parenchymatous)  and  connective-tissue  (interstitial)  forms.  Either 
of  these  forms  is  benign  or  malignant,  and  may  be  cystic  or  solid.  A 
combination  of  the  parenchjrmatous  and  interstitial  forms  are  the  so- 
called  mixed  tumors.  From  these  sources  are  derived  the  benign  and 
malignant,  the  cystic  and  the  papillary  tumors. 


XEW-FORMATIOXS   OF   THE  OVAEY 


707 


A  typical  adenoma  is  rarely  seen.  More  often  there  is  a  combi- 
nation ot  adenoma  and  fibroma  (adenofibroma).  When  the  dand 
spaces  Tviden  we  speak  of  cystadenoma.     These  large  cvstic  spaces 


Fig.  474 


MultUocular  cyst  of  the  ovarj-.  The  ovarj-  is  converted  into  two  large  cvsts  with  serous  contents 
A  fresh  corpus  lut«um  is  seen  on  the  surface  of  the  smaUer  cyst.  The  tube  is  normal.  (Specimen 
removed  by  Dr.  J.  Clarence  Webster.) 


708       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

result  from  the  distention  of  glands  by  the  retained  secretions  (non- 
proliferating  cysts)  and  from  proliferation  of  the  epithelial  and 
connective-tissue  elements,  in  addition  to  the  distention  of  the  glands. 

The  secretion  of  these  cysts  differs.  Pfannenstiel  introduced  the 
terms  cystadenoma  pseudomucosum  when  the  contents  are  of  a  mucous 
character,  and  cystadenoma  serosum  when  the  contents  are  serous  fluid. 

The  purely  granular  type  may  be  found,  or  papillae  may  spring 
from  the  surface  of  the  cyst.  It  is  possible  to  have  a  papillary  cyst 
on  one  side  and  a  glandular  cyst  on  the  other.  One  may  be  intraperi- 
toneal and  the  other  extraperitoneal.     They  are  rarely  of  equal  size. 

Fig.  473 


Multilocular  proliferating  cyst  of  the  ovary.  There  are  numerous  small  cysts  and  one  large,  thin- 
_walled  one.  Such  a  cyst  is  not  self-limited  in  its  growth,  and  may  attain  an  enormous  size.  (Specimen 
removed  by  Dr.  J.  Clarence  Webster.) 


Intraperitoneal  cysts  are  pedunculated  and  are  usually  freely.movable, 
while  extraperitoneal  cysts  seldom  have  a  pedicle  and  are  fixed.  Such 
extraperitoneal  cysts  are  usually  completely  enfolded  in  the  broad 
ligament,  but  are  sometimes  partly  within  the  free  peritoneal  cavity. 
Cysts  of  very  large  dimensions  may  have  but  a  single  cavity,  but,  as 
a  rule,  one  or  more  smaller  cysts  lie  within  the  parent  cyst  and  are 


PLATE   XXXII 


Multilocular  Pseudomucinous  Cystadenoma  of  the  Ovary. 

(Hertzler.) 


PLATE    XXXIII 


Cross-section  of  a  Pseudomucinous  Cystadenoma  of  the  Ovary. 

(Hertzler.) 


NEW-FORMATIONS  OF  THE  OVARY 


709 


known  as  daughter  cysts.  These  smaller  ones  may  give  an  irregular 
surface  and  a  variable  consistency  to  the  original  cyst.  By  rupture 
of  the  daughter  cysts  into  the  parent  cyst,  a  multilocular  cyst  may  be 
converted  into  a  unilocular  cyst.  There  are  usually  some  remnants 
of  the  walls  of  the  daughter  cysts  left  in  the  form  of  ridges  and  bands. 
As  the  cyst  enlarges  the  wall  becomes  thinner,  more  transparent, 
and  glistening.  In  the  wall  of  the  cyst  many  bloodvessels  are  seen 
to  take  an  irregular  course;  the  veins  are  larger  and  more  numerous 
than  the  arteries. 

Fig.  474 


Cross-section  of  a  multilocular  pseudomucinous  cyst  of  the  ovary.    The  parent  cyst  contains  a  number 
of  daughter  cysts  of  similar  structure  and  containing  a  mucinous  substance. 

Villous  projections  are  frequently  seen  growing  from  the  inner 
surface  of  the  cyst  wall.  The  villosities  vary  in  size  and  extent  and 
form  wart-like  excrescences,  sometimes  long  and  slender,  like  a  feather. 
The  framework  of  the  papillae  is  of  connective  tissue  in  which  blood- 
vessels course.  Covering  the  stroma  are  one  or  more  layers  of  columnar 
epithelium,  showing  many  irregular  foldings  and  reduplications  which 
might  be  mistaken  for  malignant  proliferation.  The  connective-tissue 
growth  does  not  keep  pace  with  that  of  the  epithelium.  Similar  papillary 
growths  appear  on  the  external  surface  of  the  cyst.  These  arise  either 
from  the  surface  epithelium  or  from  within  the  cyst,  and  subsequently 
penetrate  the  wall. 


710       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Microscopic  examination  of  the  cyst  wall  shows  a  vascular  frame- 
work of  connective  tissue  with  more  or  less  round-cell  infiltration. 
In  the  smaller  cysts  true  ovarian  tissue  is  sometimes  present.  On 
the  outer  surface  of  the  cyst  wall,  germinal  epithelium  is  commonly 
seen,  though  it  may  be  partially  or  wholly  lost.  The  inner  surface 
is  lined  with  a  secreting  epithelium  of  cylindrical  form  and  often  ciliated. 
This  epithelium  remains  intact,  whatever  the  size  and  age  of  the  cyst. 
To  the  unaided  eye  the  inner  surface  appears  not  unlike  the  mucous 
membrane  of  the  stomach. 


Pseudomucinous  ovarian  cyst.  The  cyst  is  lined  within  by  a  single  layer  of  high  columnar  epi- 
thelium with  an  oval  nucleus  near  the  base  of  the  cell.  The  cyst  wall  is  composed  of  connective  tissue 
containing  gland-like  structures. 

When  nutrition  is  insufficient  certain  retrogressive  changes  follow. 
Occasionally  the  cyst  contents  are  absorbed,  and  the  cyst  wall  contracts, 
thereby  diminishing  its  size. 

Calcareous  degeneration  of  the  cyst  wall  may  be  partial,  or,  as  in 
the  case  of  Leopold,  complete. 

Other  secondary  changes  in  the  cyst,  to  be  described  later,  are 
hemorrhage  into  the  cyst,  torsion  of  the  pedicle,  rupture  of  the  wall, 
infection  of  the  contents,  and  malignant  degeneration. 

Rupture  of  a  cyst  may  be  followed  by  closure  of  the  rent  and  refilling 
of  the  cyst,  or  the  rent  m_ay  remain  open  and  the  contents  be  discharged 


NEW-FORMATIONS  OF  THE  OVARY  711 

continuously  into  the  peritoneal  cavity.  In  exceptional  cases  the  cyst 
shrinks  and  disappears  after  rupture. 

If  the  contents  of  the  cyst  are  serous,  the  escaped  fluid  will  be  absorbed, 
but  if  mucus  escapes  into  the  peritoneal  cavity,  absorption  is  slow  and 
a  pseudomyxomatous  peritonitis  may  possibly  develop.  Small  hemor- 
rhages into  the  cyst  wall  are  of  common  occurrence,  and  have  no  clinical 
significance.  Hemorrhagic  effusions  into  the  cyst  wall  predispose  to 
rupture,  and  life  may  be  endangered  by  the  rupture  of  large  bloodvessels. 

When  torsion  of  the  pedicle  shuts  off  the  blood  supply  and  there 
are  no  adhesions  through  which  nourishment  is  carried  to  the  cyst, 
atrophy  or  gangrene  of  the  cyst  will  follow.  It  is  possible  for  adhesions 
to  convey  sufficient  blood  to  fully  nourish  the  cyst  and  even  permit 
it  to  increase  in  size. 

Fig.  476 


\^'-,^'a 


c^'-'i 


Multilocular  papillomatous  cyst  of  the  ovary.  An  irregular  multilocular  cyst  of  the  ovary  has  on 
its  surface  a  large  irregular  area  of  benign  papillomatous  growths.  These  warty  growths  tend  to  spread 
over  the  surface  of  the  cyst  and  over  all  peritoneal  surfaces  in  the  abdomen.  The  extension  of  the 
growth  is  by  continuity  of  tissue,  not  by  metastasis  in  the  benign  form. 

(a)  Cystandenoma  pseudomucinosum  (Hammarstan)  contains  a 
mucinous  secretion,  clear  and  transparent,  or  turbid  from  cell  debris 
and  blood.  A  large  amount  of  blood  may  give  a  chocolate  color  to 
the  fluid.  White,  flocculent  particles  float  in  the  fluid.  These  consist 
of  mucin,  cell  debris,  cholesterin,  blood  corpuscles,  and  fat  droplets. 
The  epithelium  lining  the  cyst  is  a  single  layer  of  high,  slender,  cylin- 
drical cells,  with  clear,  transparent  bodies  and  oval  nuclei  near  the 
base. 

The  pseudomucinous  cysts  are  by  far  the  most  common  of  the  large 


712       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

ovarian  cysts.  They  are  commonly  adenomatous,  rarely  papillomatous, 
though  a  limited  number  of  papillary  growths  are  often  found  projecting 
from  the  cyst  wall. 

According  to  ^Martin  more  than  two-thirds  are  unilateral  and  only 
about  7  per  cent,  are  extraperitoneal.  The  largest  recorded  cyst 
weighed  245  pounds. 

(6)  Cystadenoma  serosum  contains  a  clear  serous  fluid  of  a  pale 
green  color;  it  is  rarely  turbid  from  admixture  with  cell  debris,  or 
chocolate  color  from  admixture  with  blood. 


Fig.  477 


Cross-section  of  a  multilocular  papillomatovis  cyst  of  the  ovary.  Growing  from  the  outer  and  inner 
surface  of  the  cyst  are  papillarj-  growths.  The  contents  of  the  cyst  is  serous  fluid.  Microscopic 
examination  of  a  papillomatous  growth,  including  the  cyst  wall,  shows  the  growth  to  be  benign. 


These  cysts  rarely  attain  the  enormous  size  of  the  mucinous  variety. 
They  are  frequently  papillary^  and  as  such  are  often  bilateral. 
-    Papillary  gro'U'ths  may  not  only  cover  the  inner  surface  of  the  cyst 
and  penetrate  to  the  outer,  but  may  spread  by  continuity  of  tissue  to 
the  peritoneum,  where  by  mechanical  irritation  ascitic  fluid  is  secreted. 

A  papillomatous  growth  of  the  ovary  without  cystic  formation  is 
an  unusual  condition.  The  secreting  epithelium  consists  of  low,  cylin- 
drical-shaped cells,  with  round  nuclei  near  the  centre. 

Carcinoma. — Our  knowledge  of  primary  carcinoma  of  the  ovary  is 
very  limited.    The  majority  of  carcinomata  are  secondary. 


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NEW-FORMATIONS  OF  THE  OVARY  713 

Classification. — Waldeyer  gives  the  following  classification: 

1.  Simple   (carcinoma  simplex). 

2.  Medullary  (carcinoma  meduUaris). 

3.  Scirrhus   (carcinoma  scirrhosum). 

Many  secondary  forms  may  be  added,  such  as  atrophic,  colloid, 
melanotic,  sarcomatous,  gelatinous,  and  microcystic. 

The  frequency  of  carcinoma  of  the  ovary  is  stated  by  Martin  as 
13.6  per  cent,  of  his  cases  of  ovarian  tumors. 

About  three-fourths  of  them  are  unilateral.  Bilateral  invasion  of 
the  ovary  is  always  associated  with  involvement  of  the  peritoneum 
and  other  structures,  and  hence  is  inoperable. 

As  pointed  out  by  Sutton,  it  is  a  curious  rule  that  organs  which  are 
frequently  the  seat  of  primary  carcinoma  are  rarely  the  seat  of  secondary 
deposits,  and  vice  versa.  This  is  exemplified  in  the  ovary.  In  primary 
carcinoma  of  the  mammary  gland  the  ovaries  were  invaded  5  times  in 
85  cases  (Coupland).  Sutton  found  the  ovaries  invaded  6  times  in 
52  cases  of  inoperable  carcinoma  of  the  uterus,  and  3  times  in  29  cases 
of  inoperable  carcinoma  of  the  breasts. 

Olshausen  says  an  important  feature  in  the  clinical  history  of  ovarian 
cancer  is  the  fact  that  it  often  occurs  at  an  early  age,  and  may  even 
develop  during  childhood.  The  following  table  was  constructed  by 
Olshausen : 

8  to  19  years '    ....  19  patients 

20  to  29  years 17  patients 

30  to  39  years 8  patients 

40  to  49  years 15  patients 

50  years  and  above 17  patients 

Anatomical  Diagnosis. — In  solid  carcinomatous  tumors  of  the  ovary, 
the  general  form  of  the  ovary  is  maintained.  The  surface  is  uneven 
and  studded  with  tubercles,  nodules,  or  papillary  growths.  Rarely 
is  the  surface  smooth.  It  is  unusual  to  find  normal  ovarian  tissue,  yet 
the  occurrence  of  pregnancy  in  bilateral  involvement  of  the  ovaries 
shows  that  some  follicles  remain  healthy.  In  the  large  tumors  cystic 
spaces  are  invariably  present.  jMalignant  degeneration  of  ovarian 
cysts  is  of  more  common  occurrence.  In  all  forms  of  carcinoma  of  the 
ovary,  the  carcinoma  cells  maintain  their  cylindrical  shape  and  form 
cancer  nests  or  gland-like  structures,  not  unlike  those  found  in 
carcinoma  of  the  Fallopian  tube. 

Papillary  growths  which  have  perforated  a  cyst  wall  are  prone  to 
undergo  malignant  degeneration  and  to  rapidly  spread  to  the  peri- 
toneum. As  pointed  out  by  Abel,  when  cancerous  degeneration  is 
suspected,  the  cyst  should  not  be  tapped  before  removal  for  fear  of 
contaminating  the  peritoneum   and   setting   up   metastatic   growths. 

Metastasis  does  not  occur  so  widely  in  carcinoma  of  the  ovary  as 
in  carcinoma  of  the  uterus.  The  most  likely  points  of  invasion  are 
the  peritoneum,  omentum,  and  retroperitoneal  glands. 

Squamous-cell  carcinoma  of  the  ovary  has  been  observed  in  dermoid 
cysts. 


714       TUMORS  OF  THE  PELVIC  LIGAMEXTS  AXD  OVARIES 

Dermoid  Cysts. — Dermoid  cysts,  as  the  name  suggests,  are  cystic 
tumors  containing  skin  structures. 

In  ^Martin's  classification  we  find  simple  dermoid  cysts,  complicated 
dermoid  cysts,  cystic  teratoma,  and  solid  teratoma. 

A  simple  dermoid  cyst  is  a  sac  lined  with  a  dermal  membrane.  A 
complicated  dermoid  cyst  is  lined  with  skin  and  contains  heterogeneous 
structures,  such  as  glands,  bone,  and  teeth.  A  cystic  teratoma  contains 
formed  organs,  such  as  brain,  mammary  glands,  thyroid  glands,  etc. 
A  solid  teratoma  contains  no  large  cysts  and  is  composed  of  structures 
similar  to  those  found  in  ordinary  teratomata. 

Fig.  47S 


Miiltiloeular  dermoid  cjst. 


Anatomical  Diagnosis. — A  dermoid  cyst  may  occupy  part  or  all  of 
the  ovary,  and  as  many  as  five  distinct  and  separate  dermoids  have 
been  found  in  the  same  ovary.  They  are  commonly  intraperitoneal 
and  are  rarely  found  between  the  layers  of  the  broad  ligament.  Both 
skin  and  mucous  membrane  are  found  in  these  cysts.  The  amount  of 
skin  found  varies  greatly.  It  may  completely  line  a  large  cyst  or  may 
be  confined  to  a  single  daughter  cyst. 

Foreign  structures  found  in  dermoids  are  hair,  teeth,  nails,  horns, 
sebaceous  and  sudoriparous  glands,  mammae,  bone,  unstriped  muscle 
fiber,  brain,  and  nerve  tissue. 

The  hair  mav  be  rolled  into  a  ball  and  lie  free  in  the  cyst  cavity, 


NEW-FORMATIONS  OF  THE  OVARY  715 

or  tufts  of  hair  may  spring  from  the  cyst  walL  The  hair  has  been  known 
to  be  five  feet  in  lengh  (Munde).  The  color  varies  from  blond  to  black, 
and  does  not  usually  correspond  to  the  color  of  the  patient's  hair.  It 
is  known  to  turn  gray  in  old  age,  and  at  this  time  the  cyst  may  become 
bald. 

The  teeth  may  be  embedded  in  bone,  resembling  a  rudimentary  jaw, 
or  may  be  lodged  in  the  fibrous  wall  of  the  cyst.  More  than  400  teeth 
have  been  found  in  a  single  dermoid  cyst  of  the  ovary.  They  represent 
teeth  of  every  description,  and  develop  on  the  same  plan  as  teeth  in  the 
normal  situation.  They  are  not  scattered  irregularly  through  the  cyst 
unless  present  in  large  numbers,  but  are  grouped  together.  Nails  and 
horns  project  from  the  surface  of  the  cyst.  Sebaceous  and  sweat  glands 
may  be  numerous,  and  may  form  retention  cysts.  Bone,  in  shapeless 
masses  or  in  plates,  is  occasionally  found.  Nerve  matter  has  been 
detected  in  dermoid  cysts. 

Mammse,  in  the  form  of  a  nipple  attached  to  rounded  projections 
of  tissue  containing  sebaceous  glands  and  more  or  less  fat,  are  occa- 
sionally found,  and  completely  formed  glandular  structures  have  been 
recognized.  Dr.  Desiderius  reported  a  case  in  which  a  mammary  gland 
in  a  sebaceous  cyst  secreted  milk  and  colostrum. 

Dermoid  cysts  of  the  ovary  have  occurred  at  all  periods  of  life, 
from  birth  to  eighty  years  of  age,  and  are  the  most  common  abdomi- 
nal tumor  in  girls  and  young  women.  The  rate  of  grow^th  varies 
from  a  few  months  to  many  years  in  attaining  the  maximum  size. 
They  are  rarely  larger  than  the  patient's  head,  and  may  be  self-limiting 
in  their  growth.  As  a  rule,  adhesions  bind  the  cyst  to  the  intestine. 
Suppuration  and  malignant  degeneration  are  the  peculiar  character- 
istics of  dermoid  cysts  of  the  ovary. 

Connective-tissue  New-formations. — Fibroma,  myoma,  myxoma, 
enchondroma,  osteoma,  angioma,  lymphangioma. 

Fibroma. — Of  the  connective-tissue  tumors  of  the  ovary,  fibroma 
is  the  most  frequent.  They  are  found  with  about  equal  frequency 
betw^een  the  ages  of  twenty  and  fifty,  and  have  been  met  with  as  early 
as  ten  or  as  late  as  eighty  years  of  age.  Peterson^  reports  two  of  his 
own  cases  and  reviews  the  literature  of  eighty-two  cases.  The  largest 
number  occurred  between  the  ages  of  forty  and  fifty  years.  Peterson 
finds  no  marked  menstrual  irregularities  in  these  cases.  The  growth 
is  usually  slow,  but  may  be  quite  rapid.  Pain  was  experienced  in 
more  than  half  of  the  cases.  Ascites  was  present  in  about  40  per 
cent,  of  the  cases.  No  satisfactory  explanation  is  given  for  the 
occurrence  of  ascites.  In  13  per  cent,  there  were  calcareous  deposits 
in  the  tumors,  and  cystic  spaces  were  common. 

Orthmann  classifies  fibroids  of  the  ovary  as  superficial  and  diffuse. 

(a)  Superficial  fibroids  are  commonly  small,  rarely  larger  than  a 
walnut.  They  are  single  or  multiple,  and  sessile  or  pedunculated  in 
their  attachment  to  the  tunica  albuginea.    Their  consistency  is  firm, 

1  American  Gynecology,  i,  No.  1. 


716       TUMORS   OF   THE  PELVIC   LIGAMEXTS   AXD   OVARIES 

and  the  external  surface  is  smooth  or  furrowed.  On  cross-section  whorls 
and  bands  of  fibers  are  seen.  Germinal  epithelium  covers  the  surface 
of  the  tumor. 

(6)  Diffuse  fibroids  have  rarely  grown  larger  than  a  man's  head. 
Clemens  reported  one  weighing  40  kilos.  The  contour  varies  from 
round  and  smooth  to  irregular  and  nodular.  The  amount  of  blood 
supply  is  variable,  and  hence  the  color  of  the  tumor  varies  from  a 
pale  green  to  a  yellowish  red.  Unless  there  are  degenerative  changes 
their  consistency  is  uniformly  firm. 

Adenofibroma  of  the  ovary  is  an  occasional  finding  and  consists  of 
glandular  tissue  in  a  fibrous  framework. 


Fibroma  of  ovary.     1.3  s  11  x  10  centimeters.     (Peterson.) 


Myoma. — The  origin  of  myoma  of  the  ovary  is  probably  in  the  muscle 
fibers  of  the  vessel  walls  and  the  ovarian  ligament.  They  are  rare. 
None  larger  than  a  man's  fist  have  been  reported.  In  general  appearance 
they  closely  resemble  fibroids. 

Myxoma. — ]\I\-xoma  ovarii  appears  as  a  degenerative  form  of 
ovarian  tumors,   not  as  a  primary  gro^^th. 

Enchondroma  and  Osteoma. — Enchondroma  and  osteoma  are  second- 
ary changes  in  preexisting  ovarian  tumors. 

Angioma  and  Lymphangioma. — Angioma  and  lymphangioma  are 
extremely  rare.    A  congenital  angioma  is  described  by  Orth. 

Sarcoma. — About  4  per  cent,  of  ovarian  tumors  are  sarcomatous. 
They  occur  with  greatest  frequency  at  the  time  of  puberty  and  the 
menopause.  In  66,190  malignant  tumors  of  the  ovary  96  were  sarcomata." 
They  are  found  at  any  period  of  life,  from  birth  to  old  age.    The  periods 


PLATE    XXXVI 


^^'  < 


Endothelioma  of  the  Ovary.     (Hertzler.) 


NEW-FORMATIONS  OF  THE  OVARY  717 

of  puberty  and  the  menopause  are  the  most  frequent  (Zangemeister) . 
Doran  found  a  sarcoma  of  the  ovary  in  a  seven  months'  fetus.  Heinrichs 
reported  one  in  a  woman,  aged  seventy-four  years.  According  to 
Temesvary  the  average  age  of  the  patient  is  thirty-two  years.  Pfan- 
nenstiel  found  sarcoma  of  the  ovary  most  frequent  between  the  ages 
of  twenty-one  and  thirty.  In  25  cases  Pick  found  10  occurring  before 
twenty  years  of  age. 

Primary  sarcoma  of  the  ovary  is  usually  unilateral,  while  secondary 
sarcoma  is  usually  bilateral.  The  round-cell  variety  grows  rapidly  and 
early  gives  rise  to  metastasis,  while  spindle-cell  growths  slowly  reach 
a  large  size  without  metastasis.  Sutton  says  sarcoma  of  the  ovary 
differs  from  sarcoma  found  elsewhere  in  that  both  ovaries  are  often 
simultaneously  affected.  In  121  cases  in  the  literature  the  author 
found  42,  or  about  one-third  of  the  number,  in  which  both  ovaries 
were   involved. 

Many  so-called  fibroids  of  the  ovary  are  undoubtedly  sarcomata. 
Russel  and  Shenck  described  a  sarcoma  springing  from  the  theca 
interna.  In  form  they  may  resemble  a  large  ovary  or  are  very  irregular 
and  nodular.  Their  consistency  varies  from  firm  to  soft  and  the  color 
from  pale  gray  to  reddish  white.  The  rate  of  growth  is  variable,  the 
softer  tumors  growing  more  rapidly.  Chrobak  saw  a  sarcoma  of  the 
ovary  grow  to  the  size  of  a  five  months'  pregnancy  in  a  few  months. 

The  entire  ovary  is  usually  involved,  and  both  ovaries  are  affected 
in  about  one-half  of  the  cases. 

Both  round  and  spindle  sarcoma  cells  compose  the  tumor.  About 
one-third  are  cystic.  Sarcomatous  degeneration  of  dermoid  cysts 
is  described.  Metastasis  occurs  later  in  sarcoma  than  in  carcinoma 
of  the  ovary.  Metastatic  growths  are  found  in  order  of  frequency 
in  the  peritoneum,  omentum,  wall  of  the  stomach,  pleura,  lungs,  uterus, 
liver,  diaphragm,  retrovaginal  connective  tissue,  mediastinum,  tubes, 
intestines,  and  kidney  (Temesvary). 

A  myxomatous  degeneration  of  sarcomatous  tissue  is  occasionally 
observed. 

Ascites  develops  in  60  to  70  per  cent,  of  cases.  Uterine  hemorrhage 
is  not  uncommon,  even  after  the  climacterium.  When  found  in  chil- 
dren there  is  often  a  premature  development  of  the  genitalia. 

When  the  tumor  is  not  removed,  death  results  from  rapid  spread 
of  the  disease  or  from  complications,  such  as  obstruction  of  the  bowel. 
Neighboring  structures  are  attacked  before  those  which  are  more  remote. 
The  order  of  frequency  with  which  these  organs  are  attacked  is  peri- 
toneum, omentum,  stomach,  pleura,  lungs,  uterus,  liver,  diaphragm, 
and  kidneys.  Recurrence  after  removal  of  the  primary  growth  occurs 
in  25  to  50  per  cent,  of  cases. 

Endothelioma. — ]\Iarchand  and  Leopold  first  observed  malignant 
new-formations  of  the  ovar}'  arising  from  the  endothelium  of  blood- 
vessels. They,  are  also  known  to  arise  from  the  lymph  vessels.  Few 
have  been  recognized,  but  doubtless  many  pass  for  carcinoma  and 
sarcoma. 


718       TUMORS  OF  THE  PELVIC  LIGAMEXTS  AXD  OVARIES 

Parovarian  Cysts. — The  parovarium  consists  of  a  series  of  tubules 
lying  between  the  layers  of  the  mesosalpinx.  ^Mien  the  mesosalpinx 
is  stretched  and  held  between  the  eye  and  the  light,  the  tubules  are 
seen  as  narrow  cords  running  in  parallel  lines  from  the  hilum  of  the 
ovary  to  a  longitudinal  tubule  lying  parallel  to  the  tube  and  immediately 
beneath  it  (Gartner's  duct).  The  tubules  are  lined  with  ciliated  epi- 
thelium. The  parovarium  is  homologous  with  the  vasa  afferentia  and 
epididymis  of  the  testis.  It  is  composed  of  the  persistent  excretory 
ducts  of  the  Wolffian  body. 

Fig.  480 


Parovarian  cyst.  Between  the  tube  and  ovarj-  is  a  thin-walled,  transparent  cyst  the  size  of  an 
almond.  It  lies  between  the  layers  of  the  broad  ligament,  and  was  developed  from  a  parovarian 
tubule. 


As  a  rule,  there  are  twelve  tubules.  The  tubule  running  parallel 
to  the  Fallopian  tube  and  at  right  angles  to  the  parovarian  tubules 
is  the  duct  of  Gartner,  which  in  exceptional  cases  may.  be  traced  to 
the   vagina. 

Cysts  arising  from  the  parovarium,  the  so-called  parovarian  cysts, 
are  of  common  occurrence.  As  the  cyst  develops  the  layers  of  the 
mesosalpinx  are  unfolded,  the  tube  is  crowded  upward  and  runs  over 
the  cyst,  and  the  ovary  is  crowded  downward.  The  Fallopian  tube  is 
greatly  elongated  in  large  cysts,  but  the  lumen  is  seldom  obliterated. 
The  wall  of  the  cyst  is  at  first  thin  and  transparent,  later  thick  and 
non-transparent.  The  epithelium  lining  the  cyst  is  columnar  and 
usually  ciliated  in  the  small  cysts,  while  later  the  epithelium  is  stratified 
and  flat.  In  the  very  large  cysts  the  epithelium  may  wholly  disappear 
through  pressure.  The  fluid  contents  are  clear  and  watery,  the  reaction 
is  slightly  alkaline,  and  the  specific  gravity  1002  to  1010. 

No  parovarian  cyst  has  been  recorded  in  an  individual  under  sbcteen 
years  of  age  (Sutton).  They  are  said  to  comprise  about  10  per  cent, 
of  ovarian  tumors.  Parovarian  tumors  are  rarely  adherent;  they 
seldom  suppurate,  and  are  less  liable  to  axial  rotation  than  are 
ovarian  cysts,  because  they  are  usually  fixed  by  the  broad  ligament 
and  seldom  have  a  pedicle. 


NEW-FORMATIONS  OF  THE  OVARY 


719 


The  Clinical  Diagnosis  of  New-formations  of  the  Ovary. — In  the  diag- 
nosis of  ovarian  tumors  it  is  of  the  greatest  importance  to  recognize 
a  pedicle  connecting  the  tumor  to  the  horn  of  the  uterus.  The  pedicle 
is  composed  of  the  Fallopian  tube,  broad  ligament,  and  ovarian  ligament. 
A  short,  thick  pedicle  holds  the  tumor  close  to  the  uterus,  while  a  long, 
slender  pedicle  permits  considerable  separation.  The  length  and 
thickness  of  the  pedicle  are  not  proportionate  to  the  size  of  the  tumor. 
When,  as  occasionally  happens,  the  tumor  grows  in  the  direction  of 
the  mesovarium  and  broad  ligament  it  becomes  intraligamentous. 
An  ovarian  tumor  may  be  partly  within  the  broad  ligament  and  partly 

Fig.  481 


Parovarian  cyst.  The  cyst  is  almost  round,  the  wall  is  thin  and  transparent.  There  is  but  a  single 
cavity  containing  a  watery  fluid  of  low  specific  gravity.  Covering  the  cyst  is  a  thin,  vascular  mem- 
brane which  appears  to  form  a  part  of  the  cyst  wall.  The  vascularity  of  the  cyst  wall  is  a  characteristic 
feature.    The  Fallopian  tube  is  stretched  over  the  cyst,  and  the  ovary  is  crowded  to  the  side. 


within  the  free  peritoneal  cavity.  Having  grown  between  the  layers 
of  the  broad  ligament,  the  tumor  may  burrow  to  the  left  behind  the 
sigmoid  flexure,  to  the  right  behind  the  cecum,  into  the  parametric 
tissue  behind  the  uterus,  or  between  the  bladder  and  abdominal  wall 
underneath  the  peritoneum. 

In  discussing  the  diagnosis  of  ovarian  tumors  we  will  adopt  the 
classification  of  Winter,  devised  by  him  for  convenience  of  description. 
It  is  as  follows: 

1.  Small  ovarian  tumors,  which  lie  wholly  or  in  part  within  the 
pelvis. 


720       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

2.  Medium-sized  ovarian  tumors,  which  have  grown  into  the  abdomi- 
nal cavity,  which  have  not  grown  beyond  the  size  of  a  man's  head, 
and  have  not  risen  to  the  arch  of  the  ribs. 

3.  Large  ovarian  tumors,  which  rise  to  the  arch  of  the  ribs  and 
are  in  intimate  relation  to  the  liver,  kidney,  and  spleen. 

The  Diagnosis  of  Small  Ovarian  Tumors  Which  Lie  Wholly  or  in  Part 
within  the  Pelvis. — The  tumor  may  be  closely  crowded  to  the  uterus — 
so  close  that  no  pedicle  is  detected.  It  is  always  possible  in  a  vaginal 
examination  to  insert  the  finger  between  the  supravaginal  portion  of 
the  cervix  and  the  tumor.  When  the  tumor  lies  behind  the  uterus  it 
is  especially  difficult  to  separately  outline  the  two.  Ovarian  cysts  are 
round,  the  surface  is  usually  smooth,  and  fluctuation  is  well-marked. 

Fig.  482 


Ovarian  cyst  on  cross-section,  located  behind  the  uterus.     Uterus  crowded  against  the  bladder. 


They  are  not  tender  to  pressure  unless  complicated  by  adhesions  or 
other  inflammatory  lesions. 

Solid  tumors  are  usually  more  uneven  in  outline  and  have  a  firm 
consistency.  Cystic  tumors,  with  thick  walls  and  surrounded  by  an 
inflammatory  exudate,  may  give  the  impression  of  solid  tumor  growths. 
The  uterus  may  be  crowded  to  the  opposite  side. 

Differential  Diagnosis. — To  diagnosticate  small  tumors  of  the  ovary 
from  cystic  degeneration,  chronic  ovaritis,  hematoma,  and  abscess, 
it  is  necessary  to  consider  the  history  of  the  onset  and  the  clinical 
course.  Sensitiveness  to  pressure  speaks  for  inflammatory  enlarge- 
ments, as  does  fixation.  Inflammatory  enlargements  of  the  ovary 
do  not  show  steady  growth  as  do  new-formations,  and,  furthermore, 
they  are  more  likely  to  be  bilateral.  In  inflammatory  swellings  of  the 
ovary,  the   accompanying  tube  is   often   diseased,   and   evidences   of 


NEW-FORMATIONS  OF  THE  OVARY 


721 


pelvic  peritonitis  are  frequently  found.  The  effect  of  local  applications 
is  to  reduce  the  size  of  inflammatory  swellings  of  the  ovary,  while  such 
treatments  have  no  effect  upon  new-growths. 

Cystic  Degeneration  of  the  Ovary. — Cystic  degeneration  of  the  ovary 
is  usually  associated  with  chronic  ovaritis,  and  is  to  be  distinguished 
from  new-formations  of  the  ovary  by  the  small  size  and  by  the  ten- 
dency to  self-limitation  in  growth.  Such  ovaries  are  rarely  larger  than 
a  hen's  egg. 

Uterine  Fibroids. — It  is  easy  to  mistake  pedunculated  subperitoneal 
fibroids  of  the  uterus  for  tumors  of  the  ovarv. 


Uterine  Fibroids 

1.  Rarely  occur  in  early  life. 

2.  Rarely  grow  after  the  menopause. 

3.  Rate  of  growth  is  slow. 

4.  Consistency  usually  firm. 

5.  Intimately  attached  to  the  uterus. 

6.  Tumor  may  be  attached  to  any  portion  of 

the  uterus. 

7.  Pedicle  usually  short  and  thick. 

8.  Uterus  usually  increased  in  length. 

9.  May  find  both  ovaries  normal. 

10.  Venous  murmur  heard  in  50  per  cent,  of 

large  fibroids. 

11.  Menorrhagia  common. 

12.  Functions  of  the  bladder  and  rectum  often 

disturbed. 


Ovarian  Cysts 

1.  May  occur  in  infancy. 

2.  Often  continue  to  grow  after  the  meno- 

pause. 

3.  Rate  of  growth  is  usually  more  rapid. 

4.  Fluctuating. 

5.  Less  intimately  associated  with  the  uterus. 

6.  Tumor  connected  with  the  uterine  horn. 

7.  Pedicle  may  be  long  and  slender. 

8.  No  increase  in  the  length  of  the  uterus. 

9.  One  or  both  ovaries  abnormal. 

10.  Venous  murmur  seldom  heard. 

11.  Not  common. 

12.  Not  often  disturbed. 


It  must  be  remembered  that  uterine  fibroids  may  appear  to  fluctuate 
similarly  to  a  cyst  with  gelatinous  fluid.  When  doubt  exists,  after  all 
of  the  above  points  are  considered,  an  exploratory  incision  should  be 
made. 

Tubal  Pregnancy. — (See  Chapter  IX.) 

Serous  Perimetric  Exudates. — Serous  periometric  exudates  may  be- 
come sharply  circumscribed,  slightly  or  not  at  all  tender  to  pressure, 
and  may  fluctuate  from  contained  fluid.  In  the  early  stage  the  exudate 
may  collect  in  the  pouch  of  Douglas,  and  from  its  form  and  consistency 
it  may  be  mistaken  for  an  ovarian  tumor.  Such  exudates  are  rounded 
below  and  flat  above,  while  ovarian  cysts  are  round  throughout  their 
entire  circumference.  The  consistency  may  show  variations  at  different 
points,  while  in  ovarian  cysts  the  consistency  is  usually  uniform 
throughout.  The  exudate  blends  with  the  surrounding  structures, 
and  is  inseparably  connected  with  the  uterus. 

The  history  of  infection,  the  rapid  development  of  the  mass,  and 
the  tendency  to  remain  stationary,  or  to  decrease  in  size,  are  im- 
portant factors  in  the  differential  diagnosis  of  perimetric  exudates 
from  ovarian  cysts. 

Parametric  Exudates. — Parametric  exudates  can  usually  be  differ- 
entiated from  ovarian  cysts  by  the  history  of  infection.  This  will  point 
to  an  inflammatory  origin.  The  location  of  the  mass  in  the  connective 
tissue,  in  close  proximity  to  the  vaginal  wall,  is  characteristic  of  pelvic 
cellulitis.  Ovarian  tumors  lie  on  a  higher  level.  The  consistency  of 
46 


722       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

an  inflammatory  exudate  changes  from  time  to  time,  becoming  firmer 
and  irregular,  while  the  consistency  of  ovarian  cysts  is  constant.  It 
is  often  possible  to  palpate  both  ovaries  apart  from  the  pelvic  exudate. 

The  intimate  connection  with  the  uterus,  the  ill-defined  outline, 
the  immobility  and  tenderness  to  pressure,  the  history  of  infection, 
and  the  sudden  development  of  the  mass,  together  with  its  tendency 
to  become  smaller  as  time  goes  on,  are  significant  points  in  favor  of 
the  diagnosis  of  a  pelvic  exudate. 

Pericecal  Abscess. — A  suppurating  cyst  of  the  ovary  may  be  confused 
with  an  abscess  about  the  cecum.  A  history  of  one  or  more  attacks 
of  appendicitis  and  existing  intestinal  disorders  will  be  suggestive. 
The  abscess  is  largely  confined  to  the  right  iliac  region,  and  extends 
downward  to  the  uterus,  rather  than  upward  from  the  uterus. 

Retro-uterine  Hematocele. — Retro-uterine  hematocele  occupies  the 
pouch  of  Douglas,  and  may  be  so  moulded  as  to  suggest  an  ovarian 
tumor.  A  hematocele  is  less  tense  and  elastic,  and  does  not  fluctuate. 
There  is  no  attachment  by  a  pedicle  to  the  horn  of  the  uterus,  and  it 
may  be  possible  to  palpate  both  ovaries  apart  from  the  mass.  A  his- 
tory of  ruptured  tubal  pregnancy  is  often  elicited.  An  exploratory 
puncture  or  incision  will  disclose  the  blood. 

Intraligamentous  hematoma,  in  its  early  development,  occupies  a 
position  altogether  impossible  for  an  ovarian  tumor,  and,  later,  as  it 
dissects  around  the  uterus,  it  cannot  be  confounded  with  an  ovarian 
tumor.  The  low  situation  of  the  mass,  its  ill-defined  outline,  the  absence 
of  fluctuation,  its  tendency  to  become  smaller  instead  of  progressively 
enlarging,  and,  finally,  an  exploratory  puncture  or  incision  will  deter- 
mine the  diagnosis.  There  is  usually  a  history  of  ectopic  pregnancy 
with  rupture  of  the  gestation  sac. 

A  retroflexed  yregnant  uterus  has  been  mistaken  for  an  ovarian  cyst. 
The  usual  signs  of  pregnancy  are  to  be  considered.  In  ovarian  cysts 
it  is  possible  to  have  amenorrhea-,  enlargement  of  the  mammae,  secretion 
of  colostrum,  discoloration  of  the  cervix  and  vagina,  and  nausea. 
These  signs,  together  with  a  rapidly  growing  abdominal  tumor,  will 
suggest  pregnancy. 

The  rate  of  growth  of  a  pregnant  uterus  is  more  rapid  than  that 
of  an  ovarian  cyst.  Its  consistency  is  soft  and  elastic,  as  contrasted 
with  the  tense  elasticity  of  an  ovarian  cyst.  So  long  as  there  is  a 
suspicion  of  pregnancy,  the  sound  should  not  be  employed.  When  in 
doubt  as  to  the  diagnosis,  and  immediate  interference  is  not  necessary, 
the  patient  should  be  kept  under  observation  for  several  weeks  to  note 
the  progress  of  the  tumor  and  the  development  of  positive  signs  of 
pregnancy. 

The  Diagnosis  of  Ovarian  Tumors  of  Medium  Size. — A  tumor  lying  at 
the  brim  of  the  pelvis  that  is  round  or  oval,  sharply  outlined  and 
fluctuating,  is  in  all  probability  an  ovarian  cyst.  If  it  can  be  demon- 
strated that  the  tumor  is  attached  to  the  horn  of  the  uterus  by  a  pedicle, 
the  diagnosis  is  confirmed.  It  is  most  essential  to  recognize  the  pedicle, 
and  this  is  usually  possible  when  the  conditions  for  examination  are 


NEW-FORMATIONS  OF  THE  OVARY 


723 


favorable.  When  the  pedicle  is  difficult  to  palpate,  Hagar  advises 
traction  on  the  cervix  by  a  tenaculum  while  a  recto-abdominal  exami- 
nation is  carried  out. 

Winter  further  advises  traction  on  the  tumor  by  an  assistant,  as 
shown  in  Plate  X.  In  this  manner  the  pedicle  is  made  taut  and  can 
be  more  readily  recognized.  When  the  pedicle  cannot  be  palpated 
the  diagnosis  must  rest  upon  the  consistency  and  general  outline  of 
the  uterus. 

Fig.  483 


Elevating  a  pelvic  tumor  to  demonstrate  its  origin  in  the  pelvis 


Pregnancy  in  the  second  and  third  trimester  can  only  be  confounded 
with  an  ovarian  tumor  when  there  is  no  evidence  of  the  presence  of 
a  fetus.  There  will  be  still  greater  uncertainty  in  the  diagnosis  when 
it  is  not  possible  to  demonstrate  the  direct  continuity  of  cervix  and 
body,  because  of  the  high  position  of  the  uterus. 

The  uterine  souffle  is  seldom  heard  in  ovarian  cysts. 

Advanced  Ectopic  Pregnancy. — The  history  of  pregnancy,  together 
with  the  finding  of  an  abdominal  tumor  of  unequal,  soft  consistency 
and  absence  of  fluctuation,  will  usually  suffice  for  the  exclusion  of  an 
ovarian  cyst.  W^hen  the  fetus  is  living,  it  is  scarcely  possible  to  mis- 
take the  tumor  for  an  ovarian  cyst.  With  the  death  of  the  fetus  all  signs 
of  pregnancy  may  disappear.  The  uterus  in  an  ovarian  cyst  is  normal 
in  size,  while  in  advanced  ectopic  pregnancy  it  fairly  resembles  a 
pregnant  uterus  at  the  third  month. 

A  distended  bladder  may  resemble  an  ovarian  cyst  in  general  outline, 
position,  and  consistency.  In  every  pelvic  examination,  for  whatever 
lesion,  it  is  always  advisable  to  make  sure  that  the  bladder  is  empty. 
If  this  rule  is  observed  there  will  be  no  question  as  to  the  differential 


724       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

diagnosis  of  an  ovarian  cyst  from  a  greatly  distended  bladder.  When 
such  a  question  arises  the  catheter  will  obviate  all  possible  error 
(Fig.  484). 

Tumors  of  the  omentum  rarely  simulate  ovarian  tumors.  They  are 
seldom  so  sharply  circumscribed  and  rounded,  and  are  not  attached 
to  the  uterus  by  a  pedicle.  The  finding  of  the  ovaries  apart  from  the 
tumor  will  exclude  the  possibility  of  an  ovarian  tumor.  Omental 
cysts  have  been  tapped  for  ovarian  cysts. 

Echhwcoccus  cysts  of  the  pelvis  form  a  rounded  cystic  tumor  that 
closely  resembles  an  ovarian  cyst.  The  presence  of  a  tumor  of  the 
liver  denotes  the  presence  of  echinococci,  but  an  absolute  diagnosis  is 
only  made  by  an  exploratory  puncture  and  the  finding  of  booklets. 

Fig.  484 


Area  of  dulness  in  a  distended  bladder. 


Parovariaji  cysts  have  thin  walls  and  are  less  tense  than  ovarian 
cysts.  Unless  the  ovary  can  be  palpated  distinct  from  the  cyst,  a 
clinical  diagnosis  cannot  be  made  with  certainty. 

Phantom  tumors  of  the  abdominal  wall,  caused  by  muscular  con- 
traction and  gas  distention,  may  simulate  an  ovarian  cyst  in  form  and 
consistency.  The  swelling  has  no  connection  with  the  uterus  and  will 
disappear  under  anesthesia. 

The  Diagnosis  of  Large  Ovarian  Tumors  Filling  the  Abdominal  Cavity. — 
It  is  often  impossible  to  palpate  the  pedicle  because  of  the  close  proxi- 
mity of  the  large  tumor  to  the  uterus.  When  it  is  demonstrated  that 
the  swelling  is  a  cystic  tumor  and  not  free  fluid,  the  diagnosis  of  an 
ovarian  cyst  is  highly  presumptive,  because  it  is  most  unusual  for  a 


NEW-FORMATIONS  OF  THE  OVARY  725 

cystic  tumor  of  such  size  to  grow  from  any  other  source  than  the  ovary. 
The  superficial  veins  of  the  abdominal  wall  are  distended,  and  markings 
resembling  striae  gravidarum  are  usually  seen  over  the  abdomen.  The 
percussion  note  is  dull  over  the  swelling,  and  tympanitic  in  the  flanks 
and  over  the  stomach,  when  the  intestine  and  stomach  have  been 
crowded  by  the  tumor.  Changing  the  position  of  the  patient  does 
not  alter  the  outline  of  the  area  of  dulness  as  it  does  in  free  ascites. 

Fluctuation  is  easily  demonstrated.  Because  of  the  great  distention 
of  the  abdomen,  it  is  difficult  to  outline  the  uterus.  When  pregnancy 
can  be  excluded  the  uterine  sound  will  determine  the  position  of  the 
uterus.  In  cysts  of  extreme  size  the  upper  border  lies  beneath  the 
sternum  and  ribs,  bulging  them  forward;  the  tympanitic  note  of  the 
transverse  colon  and  stomach  is  lost.  The  splenic  dulness  also  is  lost, 
the  liver  dulness  cannot  be  defined  from  that  of  the  tumor,  and  the 
heart  and  lungs  are  pressed  upward.  The  abdomen  is  symmetrically 
enlarged,  hence  measurements  are  of  no  value  in  the  largest  cysts. 
Those  of  smaller  size  present  an  asymmetrical  enlargement  which  can 
be  demonstrated  by  inspection  and  by  certain  measurements.  These 
measurements  are  taken  from  the  umbilicus  to  the  anterior  superior 
spine  of  the  ilium,  and  from  the  linea  alba  to  the  spine  of  the  vertebrae. 
A  comparison  of  the  measurements  of  the  two  sides  will  afford  reliable 
information.  Auscultation  is  of  little  service.  A  bruit  is  sometimes 
heard,  and  will  serve  to  differentiate  the  cyst  from  ascites. 

Differential  Diagnosis. — Free  ascites  is  often  mistaken  for  large  ovarian 
cysts.  Cases  occur  in  which  a  diagnosis  cannot  be  made  until  the 
abdomen  is  opened.  Still  greater  difficulty  arises  when  an  ovarian  cyst 
is  associated  with  ascites.  Much  can  be  ascertained  from  inspection 
of  the  distended  abdomen. 

Ascites  Large  Ovarian  Cyst 

1.  Diseases  of  the  heart,  lungs,  liver,  and  perito-       1.  Absent. 

neum  to   account  for  the  presence   of  the 
fluid. 

2.  Rapid  development.  2.  Development  usually  slow. 

3.  Inspection  of  abdomen.  3.  Inspection  of  abdomen. 

(a)   Enlargement  symmetrical.  (a)   Enlargement   asymmetrical   unless   the 

entire  abdomen  is  filled. 
(6)   Flattening    anteriorly    and    bulging    in  (6)   Round  anteriorly  and  flat  in  the  flanks 

the  flanks  with  patient  on  her  back.  with  patient  on  her  back. 

(c)  Lower  portion  of  abdomen  bulges  and  (c)    No  change  in  the  outline  of  the  tumor 

epigastrium  is  flattened  with  patient  by  change  of  position  of  patient, 

erect. 

(d)  Navel  prominent  and  thin.  {d)   Navel  not  prominent. 

(e)  Costal  arch  does  not  bulge.  '  (e)    Costal  arch  bulges. 

4.  Percussion  of  the  abdomen.  4.  Percussion  of  tTie  abdomen. 

(a)   Dulness  in  flanks.  (a)   Dulness  over  abdominal  prominence. 

(6)    Tympany  in  median  line.  (b)    Tympany  in  flanks  and  epigastrium, 

(c)    Change  of  area  of  dulness  by  change  of  (c)    No  such  change, 
position  of  patient. 

5.  Palpation  of  abdomen.  5.  Palpation  of  abdomen. 

(a)   No  outline  of  tumor  can  be  palpated.  (a)   Outhne  palpated. 

(6)    Fluctuation  in  all  vaginal  fornices.  (6)    More  limited. 

6.  Exploratory  puncture.  6.  Exploratory  puncture. 

Contains  serous  fluid.  Contains  serum  or  mucus 

7.  Hydragogues      and       diuretics      temporarily       7.   Have  no  effect. 

improve  the   condition. 


726       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

The  percussion  note  is  of  greatest  value  in  differentiating  free  from 
encysted  fluid.  The  area  of  duhiess  increases  as  the  fluid  collects, 
and  is  last  to  disappear  in  the  epigastrium.     In  ascites  of  extreme 

Fig.  485 


INTEST1NA1„ 

RE:so^aA^^lcs:, 


Free  fluid  in  the  abdominal  cavity.    The  dark  lines  show  the  area  of  dulness  on  percussion,  with  the 

patient  Ijring  on  her  back. 


NEW-FORMATIONS  OF  THE  OVARY 


727 


grade  there  may  be  no  area  of  tympany,  and  the  same  may  be  true  of 
very  large  ovarian  cysts.  If  the  mesentery  is  short,  the  tympanitic 
note  disappears  early;  if  long,  so  as  to  permit  the  bowels  to  float  on 


Fig.  486 


Large  ovarian  cyst.    The  dark  lines  show  the  area  of  dulness  on  percussion  in  any  position  the  patient 

may  assume. 


728       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

the  surface  of  the  ascitic  fluid,  or  to  be  crowded  in  advance  of  the 
cyst,  the  tympany  can  be  demonstrated  until  the  abdomen  is  over- 
distended. 

Certain  fallacies  must  be  guarded  against.  A  short  iliesentery  or 
the  presence  of  adhesions  may  confine  the  intestine  to  the  flanks  in 
free  ascites  and  give  a  tympanitic  note  in  this  region.  In  ovarian  cyst 
the  bowel  may  be  adherent  to  the  anterior  abdominal  wall  and  give  a 
tympanitic  note  in  the  median  line.  Gas  generated  wdthin  the  cyst 
may  give  a  tympanitic  note.  x\gain,  the  absence  of  gas  within  the 
bowel  may  give  a  dull  note  when  tympany  would  otherwise  be  found. 

In  an  ovarian  cyst  the  percussion  note  is  always  dull  over  the  tumor, 
whether  the  percussion  is  superficial  or  deep,  while  in  ascites  superficial 
percussion  may  be  tympanitic  and  deep  percussion  dull. 

It  is  especially  difficult  to  differentiate  between  ascites  and  a  thin- 
walled  cyst,  such  as  a  large  parovarian  cyst.  In  the  latter  the  fluid 
may  gravitate  to  the  dependent  portions  of  the  abdomen,  and  it  may 
not  be  possible  to  outline  the  tumor  by  palpation.  An  exploratory 
incision  may  alone  clear  up  the  diagnosis. 

As  an  aid  to  the  differential  diagnosis  of  ascites  and  ovarian  cysts. 
Landau  advises  putting  the  patient  in  the  lithotomy  position  and 
elevating  the  hips.  If  there  is  a  large  quantity  of  free  fluid  in  the 
abdominal  cavity,  the  uterus,  in  an  abdominovaginal  manipulation, 
may  be  demonstrated  to  lie  upon  a  water-cushion. 

Pancreatic  Cysts. — No  confusion  should  arise  in  the  early  develop- 
ment of  pancreatic  cysts.  They  take  their  origin  in  the  region  of  the 
pancreas  and  grow  from  above  downward.  The  most  prominent 
portion  of  the  tumor  is  located  in  the  region  of  the  navel. 

It  is  possible  for  a  small  or  moderate-sized  ovarian  cyst  with  a  long 
pedicle  to  occupy  a  similar  position.  Such  a  cyst  is  usually  more 
movable  than  a  pancreatic  cyst,  and  the  demonstration  of  its  attach- 
ment to  the  uterus  by  a  pedicle  will  determine  the  diagnosis. 

In  doubtful  cases  an  exploratory  puncture,  together  with  a  chemical 
analysis  of  the  aspirated  fluid,  will  identify  a  pancreatic  cyst.  The 
danger  of  perforating  the  stomach  is  to  be  borne  in  mind. 

Splenic  Tumor. — It  is  possible  for  a  tumor  of  the  spleen  to  extend 
to  the  inlet  of  the  pelvis,  and  when  cystic  (echinococcus),  an  ovarian 
cyst  may  be  diagnosticated.  INIost  splenic  tumors  are  solid,  and  these 
are  not  likely  to  be  mistaken  for  ovarian  tumors.  A  splenic  tumor 
grows  from  above  downward,  while  an  ovarian  tumor  grows  from 
below  upward.  The  finding  of  a  pedicle  connecting  the  tumor  with 
the  horn  of  the  uterus  identifies  it  as  ovarian  in  origin.  An  analysis 
of  the  blood  will  often  disclose  the  nature  of  a  splenic  tumor  (splenic 
leukemia,  malaria) .  The  notched  border  and  the  respiratory  movements 
of  the  spleen  are  significant.  A  number  of  cases  have  been  reported 
in  which  the  spleen  of  about  normal  size  has  occupied  the  pelvis  and 
has  been  mistaken  for  solid  tumors  of  the  ovary.  It  is  important  in 
all  such  cases  to  seek  for  a  pedicle  connecting  the  tumor  with  the  horn 
of  the  uterus.    As  a  last  resort  an  exploratory  incision  may  be  made. 


NEW-FORMATIONS  OF  THE  OVARY  729 

Tumors  of  the  Liver. — It  is  possible  for  tumors  of  the  liver  to  reach 
to  the  inlet  of  the  pelvis.  An  ovarian  tumor,  because  of  its  great  size 
or  long  pedicle,  may  reach  to  the  right  costal  arch  and  the  tumor  and 
liver  become  one  inseparable  mass. 

A  uniform  enlargement  of  the  liver  should  be  recognized  by  its 
sharp  lower  border  and  by  the  characteristic  fissure  separating  the 
right  from  the  left  lobe.  The  mass  should  move  with  respiration, 
a  fact  not  observed  in  ovarian  tumors.  An  irregular  enlargement  of 
the  liver,  as  from  echinococcus  cysts,  abscess,  and  new-formations, 
is  more  likely  to  be  mistaken  for  an  ovarian  tumor  than  is  a  uniform 
enlargement.  Here,  as  at  all  times,  it  is  essential  to  determine  the 
relation  of  the  tumor  to  the  uterus,  whether  or  not  the  tumor  is 
attached  to  the  horn  of  the  uterus  by  a  pedicle.  In  pedunculated 
tumors  of  the  liver  the  greatest  mobility  is  at  the  lower  portion  of  the 
growth,  while  in  freely  movable  ovarian  tumors  the  greatest  mobility 
is  at  the  upper  portion  of  the  tumor. 

Fatty  Tumors. — Enormous  fatty  tumors  may  spring  from  the  omen- 
tum and  subserous  tissue,  and  suggest  the  possible  presence  of  ovarian 
tumors.  Fatty  tumors  do  not  fluctuate  and  are  not  attached  to  the 
horn  of  the  uterus  by  a  pedicle. 

A  distended  gall-bladder  containing  eleven  pints  of  fluid  was  operated 
upon  by  Lawson  Tait,  who  mistook  it  for  an  ovarian  cyst. 

A  chylous  cyst  of  the  mesentery  may  attain  an  enormo^is  size,  and 
closely  simulate  an  ovarian  cyst. 

Obesity. — ^A  thick  abdominal  wall  may  suggest  the  presence  of  an 
ovarian  tumor.  It  may  be  impossible  to  say  that  an  ovarian  cyst  does 
not  exist  without  making  an  exploratory  incision. 

Allantoic  or  urachus  cysts  may  give  rise  to  suspicion  of  an  ovarian 
cyst.  They  may  attain  a  large  size,  and  are  always  found  in  the 
median  line  between  the  abdominal  wall  and  peritoneum. 

Hydronephrosis  has  been  mistaken  for  ovarian  cysts.  A  hydro- 
nephrosis may  occupy  the  pelvis  and  an  ovarian  tumor  may  occupy 
the  region  of  the  kidney.  Moreover,  a  hydronephrosis  and  an  ovarian 
tumor  may  coexist. 

The  characteristic  physical  signs  of  renal  tumors  can  usually  be 
relied  upon.  The  colon  lying  over  the  kidney  gives  a  tympanitic 
note  on  light  percussion.  In  exceptional  cases  the  bowel  may  lie  in 
front  of  an  ovarian  cyst.  In  hydronephrosis  the  tumor  usually  varies 
in  size  from  time  to  time,  and  the  diminution  in  size  is  accompanied 
by  an  abundant  flow  of  urine.  Examination  of  the  urine  may  disclose 
important  facts.  It  is  possible  for  an  ovarian  cyst  to  rupture,  and  this 
in  turn  be  followed  by  diuresis.  Hydronephrosis  is  rarely  so  movable 
as  an  ovarian  cyst.  The  ovarian  cyst  when  large  and  fixed  may  cause 
hydronephrosis  by  pressure  upon  the  kidney  or  ureter. 

The  diagnosis  of  bilateral  ovarian  tumors  is  readily  made  when,  from 
either  tumor,  a  pedicle  is  traced  to  the  uterine  horns.  The  smaller 
the  tumor,  the  easier  the  diagnosis.  In  large  tumors  the  diagnosis 
may  be  impossible.     When  in  the  absence  of  pregnancy  and  in  the 


730       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

presence  of  a  large  cystic  tumor  of  the  abdomen,  the  menses  are  sup- 
pressed, a  bilateral  ovarian  tumor  is  suspected.  The  two  tumors  are 
rarely  of  the  same  size,  and  seldom  lie  on  the  same  level.  A  furrow 
may  separate  the  two,  and  two  separate  and  distinct  percussion  waves 
may  be  elicited.  The  tumors  may  be  moved  separately  by  bimanual 
manipulation.  An  examination  under  anesthesia  will  be  of  special 
value  in  outlining  one  cyst  from  the  other.  Not  infrequently  the 
diagnosis  is  deferred  until  an  exploratory  incision  has  been  made. 

Intraligamentous  Development  of  Ovarian  Tumors. — It  is  not  always 
possible  to  recognize  an  intraligamentous  tumor  of  the  ovary  without 
opening  the  abdomen.  Such  tumors  lie  within  the  two  layers  of  the 
broad  ligament  in  close  proximity  to  the  uterus  and  are  usually  firmly 
fixed.  No  pedicle  can  be  palpated.  In  very  exceptional  cases  the 
tumor  will  distend  the  broad  ligament  and  draw  it  out  into  a  broad 
pedicle.  Such  tumors  have  some  degree  of  mobility.  Intraligamentous 
tumors  of  the  ovary  rarely  grow  to  a  large  size.  The  uterus  and  tumor 
appear  as  one  mass,  or  the  uterus  may  be  distinctly  outlined  from 
the  tumor.  In  exceptional  cases  the  tumor  may  burrow  beneath  the 
peritoneum,  behind  or  to  the  front  of  the  uterus.  When  bilateral  the 
uterus  may  be  lifted  out  of  the  pelvis. 

Ovarian  Cysts  Parovarian  Cysts 

1.  Develop  from  the  oophoron.  1.  Develop  from  the  parovarium. 

2.  Commonly  multilocular.  2.  Usually  unilocular. 

3.  May  reach  enormous  size.  3.  Seldom  large. 

4.  Growth  usually  rapid.  4.  Usually  slow. 

5.  Usually  pedunculated  and  movable.  5.  Rarely  pedunculated  and  usually  fixed. 

6.  Adhesions  about  cyst  common.  6.  Adhesions  not  common. 

7.  Tapping  not  curative.  7.  Often  curative. 

8.  Character  of  contents:  contains  albumin;  is         8.  Character  of  contents:  little  or  no  albumin; 

mucinous  or  thin  and  watery;   clear  and  clear,    watery    fluid    of    sp.    gr.    1.003    to 

transparent,  or  coffee  colored.  1.010. 

9.  Papillomatous  growths  common.  9.  Not  common. 

10.  Rarel.v  intraligamentous.  10.  Always. 

11.  Tendency  to  become  malignant.  11.  Seldom  becomes  malignant. 

12.  Rarely  self-limited  in  growth.  12.  Self-limited  in  growth. 

13.  No  ovary  visible.  13.  Ovary  attached  to  the  periphery  of  cyst. 

14.  Bloodvessels  seldom  seen  to  radiate  over  the  14.  Large,  radiating  bloodvessels  frequently  seen 

surface  of  the  cyst.  on  the  surface  of  the  cyst. 

Adherent  Tumors  of  the  Ovary. — From  an  operative  point  of  view  it 
is  important  to  recognize  the  presence  of  adhesions.  It  is  manifestly 
more  difficult  to  recognize  adhesions  in  large  cysts,  which  have  little  or 
no  range  of  motion,  than  in  small  cysts  which,  under  ordinary  condi- 
tions, are  freely  movable.  Adhesions  are  recognized  by  the  immobility 
of  the  tumor,  its  greater  or  less  degree  of  tenderness,  and,  in  exceptional 
cases,  by  palpating  the  adhesions  in  a  conjoined  examination.   . 

In  large  cysts  the  respiratory  excursions  are  less  marked  when 
adhesions  are  present.  It  may  be  impossible  to  determine  the  degree 
of  mobility  unless  an  anesthetic  is  administered.  When  the  cyst  is 
adherent  to  the  parietal  peritoneum  the  abdominal  wall  moves  with 
the  cyst;  friction  sounds  and  fremitus  may  be  heard.     Adhesions  to 


NEW-FORMATIONS  OF  THE  OVARY  731 

the  mesentery  and  intestine  may  permit  free  mobility  of  the  tumor. 
Not  infrequently  adhesions  are  recognized  only  after  the  abdomen  is 
opened. 

Torsion  of  the  Pedicle. — It  is  of  the  greatest  importance  to  make 
an  early  diagnosis  of  torsion  of  the  pedicle.  Delay  in  recognizing 
the  condition  may  result  disastrously. 

Certain  conditions  are  recognized  as  predisposing  to  this  event, 
namely,  a  long  pedicle,  ascitic  fluid,  sudden  alterations  in  the  intra- 
abdominal pressure  from  overexertion,  falls,  and  blows,  a  growing 
pregnant  uterus,  and  the  emptying  of  a  pregnant  uterus.  Torsion 
of  the  pedicle  is  said  to  occur  in  about  10  per  cent,  of  ovarian  and 
parovarian   tumors. 

Fig.  487 


Right   ovarian  cystoma,  -n-ith  acute  torsion  of  Fallopian  tube  and  mesosalpinx,  complicating  a  six 
months'  pregnancj-  (one-half  life  size).     (^larshall.) 

When  both  ovaries  are  cystic,  the  liability  to  torsion  is  about  as 
great  as  with  a  single  cyst. 

Twisting  of  the  pedicle  occurs  in  all  ages  and  in  all  kinds  of  ovarian 
tumors.  Thornton  observed  it  in  a  thirteen-year-old  girl,  and  Potter 
in  a  woman,  aged  eighty-three  years.  Dermoid  cysts  are  particularly 
liable  to  this  accident. 

i\.s  a  result  of  torsion  of  the  pedicle,  many  grave  complications  may 
arise.  Hemorrhage  into  the  cavity  of  the  cyst  may  rapidly  distend 
it,  even  to  the  point  of  bursting,  and  may  prove  fatal.  Gangrene  of 
the  cyst  will  rapidly  follow  when  the  circulation  is  completely  shut 
off;  peritonitis  is  then  inevitable.    If  adhesions  convey  sufficient  blood 


732       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

to  the  cyst,  gangrene  will  not  follow  and  the  cyst  may  remain  intact. 
It  is  possible  for  the  cyst  to  be  entirely  severed  from  the  uterus.  In 
order  that  the  cyst  may  not  undergo  speedy  destruction,  adhesions 
must  convey  a  sufficient  supply  of  blood.  The  tightness  of  the  twist 
varies  with  the  thickness  of  the  pedicle.  Tumors  of  medium  size  are 
most  liable  to  this  accident  (Fig.  487). 

The  diagnosis  cannot  be  made  with  certainty.  Having  previously 
recognized  a  pedunculated  tumor  of  the  ovary,  torsion  of  the  pedicle 
will  be  suspected,  when  the  patient  is  seized  with  severe  pain  in  the 
region  of  the  tumor,  and  at  the  same  time  the  tumor  increases  in  size 
and  is  tender  to  pressure.  Collapse  may  follow  immediately  upon  the 
twisting  of  the  pedicle.  An  absolute  diagnosis  must  be  reserved  for 
an  exploratory  incision.  Operative  interference  must  be  advised  upon 
a  provisional  diagnosis:  the  expectant  plan  of  treatment  should  not  be 
followed. 


Fig.  488 


*  Inf.-PL 


Structures  which  go  to  make  up  the  pedicle  of  an  ovarian  cj-st.    RL,  round  ligament;  T,  tube; 
Ov.L,  ovarian  ligament;  Inf.-PL,  infundibulopelvic  ligament. 


A  limited  degree  of  torsion  may  cause  no  symptoms;  there  is  pain 
of  variable  intensity  followed  by  symptoms  of  peritonitis,  including 
fever,  rapid  pulse,  tympany,  and  abdominal  tenderness.  Peritonitis 
complicating  ovarian  cysts  is  most  often  the  result  of  secondary  infection 
of  the  cyst.  Torsion  of  the  pedicle  of  an  ovarian  tumor  must  be  differ- 
entiated from  hepatic  colic,  renal  colic,  intestinal  obstruction,  stran- 
gulated hernia,  appendicitis,  ruptured  tubal  pregnancy,  and  rupture  of 
a  sactosalpinx. 

Rupture  of  an  ovarian  cyst  results  from  direct  violence,  torsion  of 
the  pedicle,  degeneration  of  the  cyst  wall,  and  hemorrhage  within  the 
cyst  and  in  the  wall  of  the  cyst.  Spontaneous  rupture  from  thinning 
of  the  cyst  wall  has  been  reported. 

When  the  cyst  ruptures  there  is  a  feeling  of  relief  from  pressure; 
the  cyst  is  no  longer  in  evidence,  but  if  sufficient  fluid  has  escaped,  the 
contents  may  be  recognized  free  in  the  abdominal  cavity.  From 
absorption  of  the  contained  fluid  the  temperature  may  be  slightly 


NEW-FORMATIONS  OF  THE  OVARY 


733 


elevated  and  the  bowels  and  kidneys  become  unusually  active.  The 
cyst  may  rapidly  refill.  Again,  it  may  fail  to  refill  and  in  this  manner 
a  spontaneous  cure  is  effected. 

Leakage  of  the  cyst  is  a  term  implying  a  slow  and  limited  emptying 
of  a  cyst  into  the  peritoneal  cavity.  The  daughter  cysts,  which  so  often 
bulge  on  the  surface  of  the  parent  cyst,  have  an  extremely  thin  wall, 
which  may  give  way  at  some  point  and  permit  the  contents  to  be  dis- 
charged into  the  peritoneal  cavity.  Secondary  cysts  also  rupture 
into  the  parent  cyst,  and  in  this  manner  a  multilocular  cyst  may  be 
converted  into  a  unilocular  cyst. 


Fig.  489 


An  adherent  multilocular  cyst  ci-owding  the  uterus  into  extreme  anteversion. 


Rupture  of  the  cyst  may  occasion  hemorrhage  that  is  either  confined 
within  the  cyst  or  escapes  into  the  free  peritoneal  cavity.  The  hemor- 
rhage may  prove  fatal;  this  is  particularly  true  of  rupture  following 
upon  torsion  of  the  pedicle.  The  escape  of  the  fluid  from  the  cyst  is 
often  hindered  by  the  plugging  of  the  rent  with  a  daughter  cyst. 

Rupture  of  an  ovarian  cyst  into  hollow  viscera  is  possible.  Dermoid 
cysts  are  particularly  liable  to  adhere  to  the  bowel  and  to  subsequently 
rupture  into  it;  such  cysts  are  invariably  infected. 

Hemorrhage  into  the  cyst  is  the  common  result  of  torsion  of  the  pedicle, 
and  the  symptoms  are  usually  masked  by  those  caused  by  the  torsion. 
Puncture  and  direct  violence  are  additional  causes  of  hemorrhage. 
A  moderate  hemorrhage   may   cause   no   clinical   symptoms.     When 


734       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

the  loss  of  blood  is  considerable  the  symptoms  are  those  of  internal 
hemorrhage,  together  with  a  rapid  increase  in  the  size  of  the  tumor, 
pain,  and  high  tension  in  the  cyst. 

Suiypiiratioti  of  an  ovarian  cyst  was  formerly  believed  to  follow 
tapping  and  the  accidental  admission  of  air.  This  is  possible,  but 
more  often  suppuration  occurs  independent  of  such  events.  Dermoid 
cysts  are  particularly  liable  to  suppurate.  The  infected  cysts  are 
invariably  adherent  to  the  bowel,  bladder,  or  vagina,  and  through 
these  adhesions  the  infection  is  conveyed  to  the  cyst. 

In  acute  cases  the  patient  dies  from  septic  infection,  unless  operative 
interference  is  instituted.  The  symptoms  of  acute  suppuration  are 
characteristic.  The  temperature  is  elevated  and  irregular,  the  pulse 
is  rapid  and  feeble,  exhaustion  and  emaciation  rapidly  develop.  The 
cyst  increases  in  size,  and  is  very  tender  to  pressure.  Sutton  has 
observed  the  temperature  to  become  subnormal  in  long-standing  cases 
with  foul-smelling  pus  contained  within  the  cyst. 

When  gas  generates  in  the  cyst  the  dull  percussion  note  gives  place 
to  tympany.  After  suppuration  the  cyst  may  discharge  its  contents 
into  the  bowel,  bladder,  vagina,  rectum,  peritoneal  cavity,  or  through 
the  abdominal  wall. 

When  a  fistulous  communication  is  established  between  the  cyst  and 
a  hollow  viscus,  the  discharge  of  pus  may  be  prolonged  indefinitely, 
and  the  patient  finally  become  exhausted.  Fragments  of  bone,  teeth, 
and  hair  have  sloughed  into  the  bladder  from  an  adherent  dermoid 
cyst.    These  fragments  may  become  the  nuclei  of  vesical  calculi. 

It  is  most  unusual  for  such  fistulse  to  close  spontaneously.  The 
infection  frequently  travels  to  the  cyst  by  way  of  the  Fallopian  tube. 
From  an  infected  tube,  adhesions  may  develop  between  the  cyst  and 
the  omentum,  bowel,  bladder,  and  abdominal  wall.  In  a  similar 
manner  the  appendix  is  the  starting  point  of  an  infection  in  and  about 
the  cyst.  Adhesions  between  the  appendix  and  cyst  must  be  looked 
for  in  the  course  of  the  removal  of  the  cyst,  otherwise  death  may  be 
caused  by  tearing  through  the  appendix  and  bowel. 

The  Diagnosis  of  Malignant  Degeneration  of  an  Ovarian  Tumor  is  of  the 
utmost  importance,  but  unfortunately  cannot  be  made  with  certainty 
without  a  microscopic  examination. 

Bilateral  ovarian  tumors  of  the  ovary  are  often  malignant,  but 
all  forms  of  benign  tumors  of  the  ovary  are  occasionally  bilateral. 
The  presence  of  ascites  is  also  suggestive  of  malignancy,  3'^et  malignant 
tumors  of  the  ovary  may  exist  without  ascites,  and  all  forms  of  new- 
gro-wi;hs  of  the  ovary  may  be  associated  with  ascites;  this  is  particularly 
true  of  papillomatous  growths. 

The  most  suggestive  signs  of  malignant  degeneration  of  newgrowths 
of  the  ovary  are  rapid  growth,  immobility  of  the  tumor,  and  their 
firm,  nodular  character.  Partial  development  within  the  broad  ligament 
is  also  said  to  be  suggestive  of  malignant  degeneration.  Metastatic 
growths  may  be  found  on  the  peritoneum  and  in  the  viscera.  Finally, 
an  exploratory  incision  will  be  required  in  many  cases,  and  even  then 


NEW-FORMATIONS  OF  THE  OVARY  735 

the  diagnosis  must  sometimes  be  deferred  for  a  microscopic  examination. 
The  consideration  of  the  age  of  the  patient  is  not  of  great  importance 
in  that  mahgnant  tumors  of  the  ovary  are  found  in  all  ages  from  the 
time  of  puberty. 

Ovarian  Tumors  Complicating  Pregnancy. — All  forms  of  ovarian  tumors 
may  complicate  pregnancy.  Probably  the  most  frequent  are  the 
dermoids,  because  they  occur  early  in  life,  grow  slowly,  and  are  often 
fixed  in  the  pelvis,  where  they  offer  obstruction  to  labor. 

The  dangers  to  be  apprehended  during  pregnancy  are: 

1.  Axial  rotation  of  the  tumor. 

2.  Rupture  of  the  cyst. 

3.  Incarceration  of  the  tumor  in  the  pelvis. 

4.  Impediment  to  respiration  when  large. 

5.  Interference  with  the  functions  of  the  abdominal  viscera  from 
pressure. 

The  dangers  to  be  apprehended  in  labor  are: 

1.  Rupture  of  the  cyst. 

2.  Torsion  of  the  pedicle. 

3.  Suppuration  of  the  cyst. 

4.  Hemorrhage  into  the  cyst. 

5.  Rupture  of  the  uterus  and  vagina. 

6.  Interference  with  the  passage  of  the  fetus  and  with  contraction 
of  the  uterus  in  the  third  stage. 

Pregnancy  and  labor  are  not  often  affected  by  the  presence  of  an 
ovarian  cyst. 

The  diagnosis  of  the  variety  of  ovarian  tumors  is  only  possible  to 
a  limited  degree.  The  diagnosis  between  a  cystic  and  solid  tumor  is 
seldom  difficult.  Fluctuation  and  an  exploratory  puncture  will 
demonstrate  the  presence  of  fluid. 

It  is  almost  impossible  to  clinically  differentiate  a  unilocular  from  a 
multilocular  cyst.  When  smooth  and  regular  in  outline  and  consistency, 
the  cyst  is  assumed  to  be  unilocular;  when  nodular  and  irregular  in 
consistency,  and  when  of  enormous  size,  it  is  assumed  to  be  multilocular. 
A  positive  statement  can  only  be  made  when  the  cyst  is  opened. 

Dermoid  cysts  are  suspected  when  a  slow-growing  tumor,  irregular 
in  outline  and  consistency,  is  observed  early  in  life. 

Papillary  cysts  are  suspected  when  the  newgrowths  of  the  ovary  are 
bilateral  or  intraligamentous,  when  ascites  accompanies  them,  and 
when  they  are  irregular  in  outline. 

Exploratory  puncture  of  ovarian  cysts  was  at  one  time  universally 
employed,  not  only  as  a  diagnostic  measure,  but  for  the  purpose  of 
emptying  the  cyst.  The  procedure  has  given  way  to  the  more  satis- 
factory and  equally  safe  method  of  exploratory  incision.  The  fluid 
removed  by  aspirating  may  be  so  characteristic  as  to  permit  a  diag- 
nosis not  only  of  the  presence  of  an  ovarian  cyst,  but  of  the  particular 
variety.  Mucinous  fluid  is  characteristic  of  a  pseudomucinous  multi- 
locular cyst  of  the  ovary.  The  serous  fluid  of  an  ovarian  cyst  cannot 
be  recognized  from  that  of  ascites. 


736       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Contrary  to  former  belief,  chemical  and  microscopic  analyses  are 
of  no  special  value  in  differentiating  the  serous  contents  of  ovarian 
cysts  from  ascites.  The  dangers  involved  in  an  exploratory  puncture 
of  a  cyst  are  infection  of  the  contents,  puncture  of  a  bloodvessel  followed 
by  alarming  hemorrhage,  injury  to  adherent  coils  of  bowel,  escape  of 
the  contents  of  the  cyst  into  the  peritoneal  cavity,  and  finally,  though 
rarely,  torsion  of  the  pedicle. 

Exploratory  incision  may  be  regarded  as  a  safer  and  more  satisfactory 
method.  The  incision  is  to  be  made  after  the  usual  preparation  for 
an  abdominal  section. 

Fate  of  Ovarian  Tumors. — 1.  Parovarian  cysts  are  self-limiting  in 
their  growth,  and  if  they  rupture  it  is  possible  that  they  will  never  refill. 

2.  Ovarian  cysts  may  disappear  after  rupture  and  torsion  of  the 
pedicle,  though  this  is  exceptional. 

3.  Simple  cysts  of  the  ovary  are  self-limited  in  their  growth,  but 
multilocular,  proliferating  cysts  are  not.  According  to  Olshausen, 
proliferating,  multilocular  cysts  will  cause  death  from  pressure  within 
three  years. 

4.  Proliferating  cysts  of  the  ovary  cause  death  by: 

(a)  Exhaustion  due  to  interference  with  nutrition,  sleep,  and 
breathing. 

(6)  Cystitis  and  pyelitis. 

(c)  Pressure  on  the  ureters,  causing  hydronephrosis,  pyonephrosis, 
and  uremia. 

{d)  Intestinal  obstruction. 

(e)  Suppuration  and  gangrene  of  the  cyst. 

(/)  Peritonitis. 

{g)  Hemorrhage. 

{h)  Impediment  to  labor. 

Ovariotomy. — Indications. — The  rule  should  be  adopted  to  remove 
all  ovarian  tumors  when  the  general  condition  of  the  individual  will  permit. 
There  are  so  many  hazards  to  encounter  in  the  life  history  of  ovarian 
tumors  that  it  is  safer  to  remove  them  in  their  early  stage  than  to 
await  possible  complications  with  their  attending  dangers.  The  fol- 
lowing is  a  brief  consideration  of  these  complications  from  the  stand- 
point of  surgical  intervention 

1.  Malignant  Degeneration. — It  is  impossible  to  recognize  malignancy 
in  an  ovarian  tumor  in  the  early  stages  of  its  development.  The  rapidity 
of  growth,  age  of  the  patient,  size  of  the  tumor,  general  condition  of 
the  patient,  presence  or  absence  of  ascitic  fluid;  these  items  are  worthy 
of  consideration,  yet  the  malignant  character  of  the  growth  may  be 
unsuspected  because  of  the  absence  of  these  suggestive  clinical  signs. 
The  only  safe  nde  is  to  operate  all  ovarian  tumors  as  early  as  jjossihle. 

2.  Torsion  of  the  Pedicle. — According  to  Sutton  about  10  per  cent, 
of  ovarian  and  parovarian  tumors  are  subject  to  rotation,  with  twisting 
of  the  pedicle.  The  experience  of  authors  differs  widely:  Spencer  Wells 
had  12  cases  in  500  ovariotomies;  Thornton,  9.5  per  cent.;  Olshausen, 
6.5  per  cent.;  Findley,  10.2  per  cent. 


NEW-FORMATIONS  OF  THE  OVARY  737 

As  a  result  of  twisting  of  the  pedicle  there  is  pain,  more  or  less  severe, 
even  to  producing  collapse,  hemorrhage  into  the  cyst  wall  and  into  its 
cavity,  rupture  of  the  cyst  into  the  peritoneal  cavity,  with  escape  of 
its  contents,  together  with  an  amount  of  blood  that  may  be  sufficient 
to  cause  death,  and  finally  the  cyst  wall  may  become  gangrenous  and 
death  ensue  from  septic  peritonitis. 

Because  of  the  frequency  with  which  tivisting  of  the  pedicle  occurs  and 
the  serious  consequences  of  this  event,  we  are  justified  in  laying  down  the 
dictum  that  every  ovarian  tumor  should  he  operated  without  unnecessary 
delay, 

3.  Suppuration. — Dermoid  cysts  are  particularly  liable  to  infection 
and  the  development  of  abscess  formation,  and  this  is  true,  to  a  lesser 
degree,  of  all  ovarian  tumors.  And,  as  a  result,  the  infection  may  become 
generalized  or  invade  neighboring  tissues,  and  fistulous  tracts  may  be 
established  with  the  bowel,  bladder,  vagina,  and  abdominal  wall.  Such 
a  complication  adds  greatly  to  the  dangers  involved  in  the  removal 
of  the  cyst  and  mitigates  against  a  perfect  recovery. 

4.  Adhesions. — Ovariotomy,  in  the  presence  of  extensive  adhesions,  is 
a  source  of  anxiety  to  the  operator.  Adhesions  would  seldom  be 
encountered  if  all  ovarian  tumors  were  operated  upon  early  in  their 
development. 

5.  Rupture  of  the  Cyst.—Rw^tnre  of  the  cyst  is  the  result  of  violence, 
of  thinning  of  the  cyst  wall  from  the  pressure  of  its  contents,  and  of 
twisting  of  the  pedicle.  This  accident  would  likewise  be  largely  elimi- 
nated by  early  operative  interference. 

6.  Functional  and  Organic  Changes  in  the  Abdominal  and  Thoracic 
Viscera  Result  from  Pressure  of  the  Tumor. — No  tumor  should  be 
permitted  to  reach  a  size  that  would  permit  of  such  complica- 
tions. 

Contra-indications  to  Operation. — Few  contra-indications  are  recognized 
for  the  removal  of  large  ovarian  tumors  or  those  which  have  developed 
serious  complications.  jMore  conservatism  may  be  entertained  in  the 
management  of  small,  uncomplicated  tumors.  General  debility,  an 
incompetent  heart,  advanced  anemia,  nephritis,  inflammatory  lesions 
of  the  air  passages,  these  and  other  possible  conditions  may  forestall, 
for  a  time  at  least,  the  removal  of  ovarian  tumors  when  uncomplicated, 
or  not  of  such  size  as  to  cause  serious  pressure  symptoms.  When 
serious  complications  exist,  or  the  tumor  is  of  such  size  as  to  be  no 
longer  tenable,  the  conscientious  surgeon  will  not  hesitate  to  attempt 
its  removal. 

Age  is  no  barrier  to  surgical  interference.  Statistics  gathered  by 
Kelly  and  Sherwood  on  ovariotomy  in  the  aged  and  by  Sutton  in 
the  young,  show  a  remarkably  favorable  outcome  of  these  cases  in  the 
extremes  of  life. 

Vaginal  Ovariotomy. — The  first  vaginal  ovariotomy  was  performed 

by  Atlee  in  1854,  but  the  practical  application  of  the  procedure  was 

made  by  Gaillard  Thomas  in   1870;  then  followed  Baker,   Martin, 

Leopold,  Battey,  and  Wing.    The  operation  did  not  find  general  favor, 

47 


738       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

but  it  may  be  said  that  at  no  time  has  it  been  so  generahy  accepted  as 
in  the  present  decade. 

It  is  possible  to  dehver  tumors  of  the  ovary  when  not  larger  than  a 
man's  fist  and  of  much  larger  size  when  not  adherent,  and  when  they 
can  be  first  emptied  of  their  contents,  either  through  an  anterior  or 
posterior  colpoceliotomy.  Operators  dift'er  in  their  choice  of  the  two 
methods  of  procedure.  Greater  space  is  afforded  by  the  anterior  route, 
and  this  is  generally  conceded  to  be  the  avenue  of  choice. 

In  the  Tubingen  clinic  24  per  cent,  of  ovarian  tumors  were  removed 
per  vaginam.  In  230  vaginal  ovariotomies  performed  by  Abel,  INIartin, 
Schauta,  and  Bumm  there  were  but  2  deaths. 


Fig.  490 


OvariotomJ^    The  ovarj-  is  severed  at  the  hilum.    Interrupted  sutures  of  catgut  are  placed  at  the  base 
to  control  bleeding-points,  and  a  continuous  suture  of  catgut  approximates  the  peritoneal  margins. 

In  order  that  the  tumor  may  be  delivered  in  toto  through  the  vaginal 
incision,  it  must  be  no  larger  than  a  man's  fist,  or  when  larger  it  must 
be  free  of  adhesions  and  capable  of  being  emptied  through  a  trocar. 
When  these  conditions  are  present  the  size  of  the  tumor  does  not  enter 
into  consideration.  It  must  be  borne  in  mind,  however,  that  the  large 
cysts  are  commonly  multilocular,  and  frequently  contain  much  solid 
tissue  which  would  be  difficult,  if  not  impossible,  to  deliver  through 
a  vaginal  incision.  "When  there  is  suspicion  of  malignancy,  and  in  all 
papillary  tumors,  the  abdominal  route  should  be  chosen. 

Technic  of  Posterior  Colpoceliotomy. — For  the  removal  of  ovarian 
tumors  through  the  posterior  vaginal  incision,  the  posterior  lip  of  the 
cervix  is  grasped  by  a  tenaculum  torceps  and  traction  toward  the  sym- 
physis is  made  by  an  assistant.  A  transverse  incision  is  made  with 
sharp-pointed  scissors  back  of  the  cervix.  This  incision  is  about  one  inch 
in  length  and  extends  only  through  the  vaginal  wall.  The  finrger  then 
burrows  up  to  the  peritoneal  fold,  which  forms  the  floor  of  the  pouch 
of  Douglas;  this  is  incised  with  scissors  and  spread  open  laterally  with 
the  fingers.  If  the  ovarian  tumor  lies  in  the  cul-de-sac,  it  can  then  be 
exposed  by  a  Simon  speculum.    If  the  tumor  is  small  and  solid,  it  may  be 


NEW-FORMATIONS  OF  THE  OVARY  739 

grasped  by  a  tenaculum  forceps  and  delivered  into  the  vagina;  if  large 
and  cystic,  it  is  grasped  by  tenaculum  forceps  and  into  it  is  thrust  a  long 
trocar,  through  which  the  fluid  is  withdrawn.  As  the  cyst  collapses 
it  is  grasped  by  long  hemostatic  forceps  and  withdrawn  through  the 
vagina.  Ordinarily  the  pedicle  will  be  long  enough  to  permit  of  the 
delivery  of  the  tumor,  leaving  the  uterus  within  the  pelvic  cavity,  but 
if  not,  the  uterus  may  be  delivered  through  the  vaginal  incision.  The 
pedicle  is  then  ligated  and  incised  as  in  abdominal  ovariotomy,  and 
the  vaginal  incision  is  closed  with  chromic  catgut. 

The  sutures  should  include  the  vaginal  walls  and  peritoneal  folds. 
If  drainage  is  required  the  incision  is  left  partly  or  entirely  open  and 
a  gauze  drain  inserted. 

Technic  of  Anterior  Colpoceliotomy. — ^The  anterior  lip  of  the  cervix 
is  grasped  by  vulsellum  forceps  and  the  cervix  is  drawn  down  to  the 
vulvar  orifice.  A  transverse  incision  is  made  through  the  vaginal  wall 
at  its  junction  with  the  cervix.  The  bladder  is  stripped  from  the  cervix 
by  the  index  finger  to  the  reflection  of  the  peritoneum.  The  peritoneum 
is  incised  and  the  opening  enlarged  with  the  fingers.  The  bladder  is 
now  freely  separated  from  the  uterus  and  vaginal  wall.  Through  this 
liberal  incision,  tumors  of  the  ovary,  the  size  of  a  man's  fist,  can  be 
delivered  and  large  cysts  may  be  tapped  with  a  trocar,  the  contents 
emptied,  and  the  collapsed  sac  withdrawn  through  the  incision  by  means 
of  heavy  clamps.  If  the  pedicle  is  of  the  usual  length  the  uterus  may 
remain  in  situ,  but  if  not,  the  body  of  the  uterus  must  be  drawn  into 
the  vagina.  The  pedicle  is  then  ligated  with  catgut,  incised,  and  the 
original  incision  through  the  vaginal  wall  closed  with  chromic  catgut. 

Abdominal  Ovariotomy. — Incision  into  the  Abdomen. — A  median 
abdominal  incision  is  made,  sufficient  in  length  to  admit  two  fingers. 
Through  this  incision  the  abdomen  is  explored,  and  if  it  is  determined  to 
proceed  with  the  removal  of  the  ovarian  tumor,  the  incision  is  extended 
to  the  required  length.  It  is  rarely  necessary  to  extend  the  incision 
above  the  umbilicus.  Caution  must  be  exercised  in  opening  into  the 
peritoneal  cavity,  in  the  presence  of  adhesions,  to  avoid  incising  the 
tumor  or  bladder,  and  injuring  adherent  coils  of  bowel. 

Evacuation  of  the  Cyst. — A  long  strip  of  sterile  gauze  is  inserted 
between  the  cyst  and  abdominal  wall  on  all  sides  of  the  incision,  leaving 
exposed  a  small  area  of  cyst  wall  immediately  below  the  incision. 

At  this  point  a  trocar  is  thrust  into  the  cavity  of  the  cyst  and  the 
contents  allowed  to  drain  off  into  a  basin.  As  the  cyst  collapses  its 
walls  are  grasped  by  forceps  on  either  side  of  the  puncture.  Traction 
is  made  upon  the  cyst  by  means  of  the  forceps,  and  as  the  cyst  is 
withdrawn,  other  forceps  are  applied  low^er  down  on  the  cyst.  The 
patient's  body  is  tilted  to  the  side  of  the  assistant  holding  the  forceps. 
If  no  adhesions  exist,  the  cyst  is  readily  delivered  from  the  abdominal 
cavity  and  the  pedicle  brought  into  the  hands  of  the  operator.  Care 
should  be  taken  to  avoid  soiling  the  peritoneal  cavity  and  hands  of 
the  operator  with  the  contents  of  the  c^'st.  A  sterile  towel  should  be 
placed  over  the  delivered  cyst  while  ligating  the  pedicle. 


740       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

When  the  contents  of  the  cyst  are  mucinous,  or  there  exist  numerous 
small  cysts,  it  may  be  necessary  to  greatly  enlarge  the  incision  to  deli^'e^ 
the  tumor  en  masse.  If  the  contents  are  infected,  the  greatest  caution 
must  be  exercised  in  protecting  the  peritoneum  and  hands. 

If  the  tumor  is  malignant  it  is  advisable  to  make  a  free  incision 
so  as  to  work  rapidly  and  to  remove  the  cyst  without  puncture. 

Breaking  the  Adhesions. — When  the  adhesions  are  not  firm,  little 
difficulty  will  be  experienced  in  severing  them  with  the  fingers.  When 
they  are  firm  and  extensive  it  is  often  best  to  sacrifice  the  outer  cover- 
ing of  the  cyst  to  avoid  injury  to  adherent  structures,  notably  the 
bowel.  Great  care  must  be  taken  to  avoid  stripping  off  the  parietal 
peritoneum,  an  accident  that  so  often  happens  in  the  beginning  of  the 
dissection  by  starting  on  the  wrong  plane.  Omental  adhesions  may 
demand  resection  of  the  adherent  portion  of  the  omentum. 

Fig.  491 


--'-Sroad  Li^meni 


Invagination  of  the  stump  of  the  tube  between  the  layers  of  the  broad  ligament. 


Ligation  of  the  Pedicle. — The  author  usually  transfixes  the  pedicle 
with  two  No.  2  plain  catgut  ligatures.  By  placing  two  separate  ligatures, 
the  chance  of  postoperative  hemorrhage  is  lessened.  Many  operators 
use  silk  or  linen  ligatures.  The  ligation  of  the  pedicle  can  be  so  made 
as  to  allow  the  turning  in  of  the  cut  surfaces  of  the  stump  to  prevent 
adhesions.  A  reliable  substitute  would  be  found  in  charring  the  ligated 
pedicle  with  the  actual  cautery;  adhesions  do  not  readily  form  on  the 
charred  surface. 

Drainage. — No  drainage  should  be  made  in  ordinary  cases.  When 
the  cyst  is  infected  and  it  is  feared  that  the  peritoneum  is  contaminated, 
drainage  should  not  be  omitted.  It  is  also  well  to  drain  when  hemor- 
rhage is  feared  and  when  extensive  raw  surfaces  are  left.  In  draining, 
the  author  prefers  an  iodoform  gauze  pack  brought  through  the  cul- 
de-sac  into  the  vagina.  This  permits  the  abdominal  incision  to  be 
closed.    The  pack  should  be  removed  at  the  end  of  forty-eight  hours. 


NEW-FORMATIONS  OF  THE  OVARY  741 

The  Opposite  Ovary. — A  close  inspection  should  be  made  of  the 
opposite  ovary.    The  following  rules  should  apply : 

1.  Greater  conservatism  is  practised  when  the  patient  is  young. 

2.  If  the  patient  is  advanced  in  years  the  entire  ovary  should  be 
removed  if  thought  to  be  similarly  affected. 

3.  In  young  individuals,  resection  of  the  ovary  may  be  made  when 
the  opposite  ovary  is  removed  for  a  benign  growth  and  the  ovary  is 
evidently  diseased. 

4.  The  opposite  ovary  must  be  removed  in  toto  if  the  tumor  is 
thought  to  be  malignant. 

Intraligamentary  Ovarian  and  Parovarian  Cysts.— The  technic  of 
removing  intraligamentary  cysts  differs  from  that  above  described  in 
that  there  is  usually  no  pedicle  to  the  tumor,  and  it  is  necessary  to 
attack  the  growth  through  an  incision  in  the  broad  ligament. 

The  broad  ligament  is  split  parallel  to  the  transverse  diameter  of 
the  pelvis  and  at  a  level  with  the  pelvic  brim.  Before  proceeding  to 
shell  out  the  cyst,  the  bloodvessels  are  ligated  on  either  side.  The  tumor 
can  then  be  readily  shelled  from  its  investment  with  little  or  no  fear 
of  hemorrhage.  The  top  of  the  broad  ligament  is  then  sutured  with 
a  running  catgut  suture. 

Not  all  cases  are  so  readily  disposed  of.  When  the  tumor  is  large, 
the  ureter  may  be  adherent  to  its  posterior  surface  and  is  liable  to 
injury.  The  peritoneum  is  lifted  from  the  floor  of  the  pelvis;  the  rectum, 
colon,  sigmoid,  and  uterus  are  displaced  and  the  visceral  layers  of  the 
peritoneum  may  be  adhered  to  the  anterior  parietal  peritoneum.  The 
removal  of  these  cysts  may  be  facilitated  by  first  withdrawing  the 
contents  through  a  trocar,  then  carefully  ligating  the  blood  supply. 
When  the  cysts  are  bilateral  and  lie  deeply  embedded,  the  safest  pro- 
cedure is  that  recommended  by  Howard  Kelly,  which  is,  to  remove 
the  uterus  and  tumors  together.  When  there  has  been  an  extensive 
dissection  of  the  pelvic  floor,  the  ureter  should  be  carefully  inspected 
before  closing  the  broad  ligament.  If  found  injured,  repair  should 
be  made  before  proceeding  to  close  the  rent  in  the  broad  ligament. 

Papillary  Cysts. — It  is  difficult  and  at  times  impossible  to  make  a 
clinical  distinction  between  benign  and  malignant  papillary  cysts  of 
the  ovary.  All  give  the  appearance  of  malignancy  to  the  naked  eye, 
and  yet  in  the  presence  of  papillary  vegetations  engrafted  on  the 
peritoneal  surfaces  of  the  abdominal  organs,  the  uterus  embedded  with 
cauliflower  growths  on  either  side  and  the  abdominal  cavity  distended 
with  fluid,  permanant  recovery  is  known  to  follow  upon  the  removal 
of  the  primary  growths.  We  are  to  distinguish  between  metastatic 
invasion  by  way  of  the  lymphatics  and  bloodvessels  and  simple  grafts 
of  detached  vegetations.  Nothing  short  of  a  microscopic  examination 
of  the  primary  growth  will  insure  a  positive  diagnosis,  and  in  so  doing, 
sections  must  be  taken  from  various  portions  of  the  tumor  because  the 
malignant  changes  may  be  circumscribed. 

The  only  safe  ride  to  adopt  is  that  of  Pozzi,  who  would  regard  all  these 
tumors  as  benign  in  the  absence  of  visceral  metastasis.     Assuming  this 


742       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

attitude,  an  attempt  is  made  to  remove  the  primary  growths  in  the  hope 
that  detached  portions  of  the  gro"«i:h  wUl  disappear  spontaneously.  If 
the  tumor  recurs  the  abdomen  should  be  again  opened  and  the  gro"v\i;h 
removed  if  possible.  A  second  and  sometimes  a  third  abdominal  section 
ma}'  be  followed  by  complete  and  lasting  cure.  Not  infrequently, 
however,  the  tumor  returns  with  all  the  evidences  of  malignancy. 

When  both  ovaries  are  involved  it  is  advantageous  to  remove  the 
body  of  the  uterus,  together  with  the  ovaries.  This  simplifies  the 
technic  and  affords  better  control  over  the  bleeding  points. 

When  one  ovary  alone  is  involved  and  the  patient  is  in  the  period 
of  sexual  maturity,  it  is  advisable  to  leave  the  healthy  ovary;  but  if 
the  woman  is  approaching  the  menopause,  both  ovaries  should  be 
removed,  because  of  the  likelihood  of  recurrence  in  the  healthy  ovary. 

Malignancy  in  Ovarian  Tumors. — By  a  study  of  statistics  from  various 
clinics  the  author  is  impressed  with  the  large  percentage  of  malignancy 
in  ovarian  tumors.  Leopold  finds  22  per  cent.,  Fritsch  17.9  per  cent., 
Blau  22.7  per  cent.,  Schultze  27  per  cent.,  Olshausen  15  per  cent., 
Doederlein  15.5  per  cent.,  Freund  21.6  per  cent.  It  may  be  safely 
affirmed  that  one  in  five  of  the  tumors  of  the  ovary  is  malignant; 
hence  the  dictum  to  view  all  tumors  of  the  ovary  with  suspicion  of 
malignancy,  and  as  an  early  clinical  diagnosis  of  malignancy  cannot 
be  made  with  certainty,  the  only  safe  rule  to  follow  is  early  removal  of 
all  such  tumors. 

There  ivere  many  contra-indications  to  the  remoral  of  ovarian  tumors  in 
former  years  but  not  so  today.  Operative  interference  should  be  delayed 
for  a  time  for  reasons  which  apply  to  surgical  operations  in  general: 
such  as  inflammations  of  the  air  passages,  deficiencies  in  the  functions 
of  the  heart  and  kidneys,  great  anemia,  exhaustion,  intercurrent  infec- 
tious diseases,  pregnancy,  and  diabetes.  For  these  reasons  the  operation 
may  be  postponed  temporarily  if  not  indefinitely. 

Age  is  no  contra-indication  when  all  other  conditions  are  favorable. 
In  extreme  old  age  no  operation  would  likely  be  advised  unless  as  a 
palliative  measure. 

The  size  of  the  tumor,  the  presence  of  adhesions,  however  firm 
and  extensive,  the  relation  of  the  growth  to  the  broad  ligaments  and 
peritoneum;  these  factors  are  no  longer  considered  contra-indications 
to  operative  interference. 

Malignancy  of  the  tumor  presents  a  questionable  contra-indication, 
but  cannot  be  viewed  in  the  light  of  an  absolute  contra-indication  unless 
demonstrated  by  direct  inspection  through ,  an  exploratory  incision. 
In  this  connection  the  conclusions  of  Pozzi,  drawn  from  his  observations 
in  papillary  growths  of  the  ovary,  are  worthy  of  serious  consideration. 
(See  page  741.) 

When  the  tumors  cannot  be  removed  for  any  of  the  above  reasons, 
and  much  suffering  is  occasioned,  relief  may  be  sought  through  tapping 
of  the  cystic  or  ascitic  fluid. 

Tapping  of  ovarian  cysts  can  only  be  looked  upon  as  a  palliative 
measure,  and  is  in  nowise  curative.     It  may  be  advisable  to  tap  large 


NEW-FORM ATIOXS  OF   THE  OVARY 


743 


cysts  one  to  four  days  before  proceeding  with  their  removal;  this  is  done 
to  minimize  the  danger  of  shock. 


Fig.  492 


Surface  left 
by  excision oj  cyst 


Fig.  493 


The  upper  figure  shows  the  raw  surfaces  left  bj"  the  excision  of  a  cyst  from  the  ovarj-.    The  lower 
figure  shows  the  approximation  of  the  wound  surfaces  by  fine  silk  sutures.     (Kelly-Noble.) 


Fig.  494 


Tuboovarian  abscess  removed  by  amputating  the  uterine  comu.     (After  T.  S.  Cullen.) 


744       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Treatment  of  Ovarian  Tumors  Complicating  Pregnancy,  Labor,  and 
the  Puerperium. — Pregnancy. — The  treatment  of  pregnancy  compli- 
cated by  the  presence  of  an  ovarian  tumor  is  one  of  watchful  expec- 
tancy so  long  as  the  pregnancy  is  permitted  to  progress  favorably  and 
the  tumor  gives  no  signs  of  serious  complications. 

Fig.  495 


Anterior  colpotomy  for  inspection  and  possible  operation  upon  the  appendages.  The  cervix  is 
drawn  forcibly  downward  and  forward  by  a  tenaculum  and  a  transverse  incision  is  made  with  scissors 
and  tissue  forceps  through  the  vaginal  wall  about  one-half  inch  above  the  external  os.    Step  I. 


The  presence  of  an  ovarian  tumor  complicating  pregnancy  will 
result  in  abortion  in  19.4  per  cent,  of  cases  (Orgler-Graef e-Heil) . 

"\^Tien  ovariotomy  has  been  performed  in  the  period  of  gestation, 
death  of  the  fetus  has  occurred  in  30  per  cent,  of  cases  (Fehling).  This 
is  an  expression  of  the  frequency  with  which  abortions  follow  ovari- 
otomy.    The  maternal  mortalit}'  of  ovariotomy  in  pregnancy  is  little 


NEW-FORMATIONS  OF  THE  OVARY 


745 


greater  than  in  ovariotomies  uncomplicated  by  pregnancy.  Orgler 
puts  it  at  2.7  per  cent.  In  fact,  the  percentage  is  possibly  less,  because 
the  tumors  are  less  likely  to  be  malignant  and  adherent,  and  the  age 
of  the  individual  is  favorable  to  a  good  result. 


Fig.  496 


Anterior  colpotomy.     The  vaginal  wall  is  stripped  upward  by  the  finger  covered  with  gauze.     The 
vesico -uterine  fold  of  peritoneum  is  exposed  to  view.      Step  2. 


The  earlier  the  operation  is  performed  in  the  period  of  gestation, 
the  better  the  chances  for  both  the  mother  and  fetus.  The  more 
advanced  the  pregnancy,  the  more  liable  are  we  to  meet  with  serious 
complications. 


746       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

The  presence  of  bilateral  ovarian  tumors  does  not  contraindicate 
operative  niterference  in  the  course  of  pregnancv.  In  event  of  a  rapid 
growth  of  the  tumor,  of  torsion  of  the  pedicle,  rupture  of  the  cyst, 

Fig.  497 


Anterior  colpotomy.    A  transverse  incision  is  made  through  the  peritoneum  and  the  body  of  the  uterus 
is  exposed  to  view.     Step  3. 

or  interference  with  the  development  of  the  gravid  uterus,  resort  must 
be  had  to  ovariotomy,  and  in  performing  the  operation  everv  means 
possible  must  be  employed  to  conserve  the  interests  of  the  'child  in 


NEW-FORMATIONS  OF' THE  OVARY 


747 


Labor.— Labor  may  progress  uninterruptedly  in  the  presence  of  a 
large  ovarian  tumor  which  lies  high  in  the  abdomen.  When  low  in 
the  pelvis,  a  tumor  of  moderate  size  may  obstruct  labor.  Again,  torsion 
of  the  pedicle  or  rupture  of  the  cyst  may  necessitate  an  abdominal 


Fig.  498 


Anterior  colpotomy.     Catgut  sutures  are  passed  through  the  vaginal  wall  and  peritoneum.     Step  4. 

section  for  the  removal  of  the  cyst.  The  effort  should  be  made  to  dis- 
lodge tumors  incarcerated  in  the  pelvis  by  bimanual  manipulations, 
in  order  to  provide  space  for  the  passage  of  the  child.  To  do  this  most 
effectively  the  knee-chest  position  is  advised.     An  anesthetic  may  be 


748       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

required,  and  if  so,  the  exaggerated  Trendelenburg  position  is  advised. 
If  it  is  found  impossible  to  deliver  the  child  and  the  tumor  is  cystic,  the 
next  mode  of  procedure  would  be  to  tap  the  cyst.  This  may  be  done 
through  the  vagina,  if  the  tumor  lies  sufficiently  low  in  the  pelvis  or 


Fig.  499 


Anterior  colpotomy.     The  peritoneum  is  sutured  to  the  anterior  vaginal  wall.     Step  5. 

through  the  abdomen,  if  high  up  and  of  a  size  and  position  to  make  the 
operation  safe  and  feasible. 

When  the  tumor  is  solid  or  semisolid,  and  when  it  cannot  be  tapped 
for  any  other  reason,  resort  must  be  had  to  an  abdominal  incision 


NEW-FORMATIONS  OF  THE  OVARY 


749 


with  removal  of  the  tumor,  after  which  a  Cesarean  section  may  be 
performed  and  the  abdomen  closed.  This  in  many  instances  would 
be  preferable  to  delivering  the  child  per  viam  naturalis  after  ovari- 
otomy. 


Fig.  500 


Anterior  colpotomy.    Deliverv-  of  the  uterus  through  an  anterior  colpotomy.    Step  6. 

Puerperium. — During  the  puerperium  the  tumor  may  become  infected 
or  torsion  of  the  pedicle  may  occur.  In  such  an  event  the  tumor  must 
be  removed  by  way  of  the  abdomen,  and  that  without  delay.  The 
puerperium  presents  no  contra-indication  to  ovariotomy. 


750       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Complications  following  Ovariotomy.— Shock  may  be  prevented  in 
the  majority  of  cases  by  a  carefuhy  administered' anesthetic,  by  pre- 
ventnig  undue  loss  of  blood,  by  avoiding  unnecessary  exposure  of 
the  bowel,  by  rapid  operating,  and  by  keeping  the  operating  room 
at  the  proper  temperature. 

Fig.  501 


Anterior  colpotomy.    DeUvery  of  the  tube  and  ovary  through  an  anterior  colpotomy.    Step  7. 

General  peritonitis  and  local  infections  do  not  follow  with  greater 
frequency  than  in  other  abdominal  operations. 


NEW-FORMATIONS  OF  THE  OVARY 


751 


Secondary  hemorrhage  was  formerly  feared  from  the  sHpping  of 
the  Hgature  about  the  pedicle. 


Fig.  502 


Anterior  colpotomy.  Inspection  of  the  tube  and  ovary.  In  this  step  the  tubes  and  ovaries  may  be 
freed  from  adhesions,  the  end  of  the  tube  may  be  resected,  part  of_the  ovary  may  be  excised,  or 
the  tube  and  ovary  may  be  wholly  removed.     Step  8. 

Bronchitis,  bronchopneumonia,  pulmonary  embolism,  and  edema 
are  occasional  complications.  Cystitis,  acute  degeneration  of  the 
heart  muscle,  and  ileus  are  also  mentioned  among  the  occasional 
postoperative  complications. 


752       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Mortality  in  Ovariotomy. — Pfannenstiel  places  the  average  mortality 
at  5  per  cent.  Segalowitz  collected  reports  of  1953  ovariotomies,  with 
a  mortality  of  7.63  per  cent.;  this  was  in  1903.     Doederlein  reports  a 


Fig.  503 


Anterior  colpotomy.     Deliverj'  of  the  body  of  the  uterus  and  both  appendages  through  an  anterior 

colpotomy.     Step  9. 


mortality  of  3.5  -per  cent.,  while  Martin,  ^Yinte^,  and  Fritsch  each 
have  a  mortality  of  about  9  per  cent.  The  causes  of  death  were 
peritonitis,  ileus,  pneumonia,  nephritis,  cachexia,  and  anemia.     In  an 


NEW-FORMATIONS  OF  THE  OVARY 


753 


uncomplicated  ovariotomy  the  mortality  should  be  almost  nil,  while 
with  the  malignant  tumors  of  the  ovary,  ovariotomy  has  a  mortality 
of  18  to  40  per  cent. 


Fig.  504 


Anterior  colpotomy. 


Ligature  of  the  tube  and  ovarian  ligament  through   an   anterior   colpotomy, 
preparatory  to  their  removal.     Step  10. 


Conservative  Operations  on  the  Ovary. — Before  entering  upon  a 
discussion  of  the  operative  measures  designed  for  the  relief  of  diseases 
of  the  ovaries,  it  would  be  well  to  state  clearly  and  emphatically 
that  not  all  lesions  of  the  ovary  demand  operative  interference. 

Cystic  degeneration  of  the  ovary  may  exist  without  giving  rise  to 
48 


754       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

serious  local  or  general  disturbances,  and  in  this  event  there  is  no 
justification  for  either  medical  or  surgical  intervention.  A  displaced 
ovary  may  give  rise  to  no  symptoms,  and  should  then  be  let  alone. 
In  the  acute  stage  of  inflammation  the  same  general  and  local  pro- 

FiG.  505 


Anterior  colpotomy.      Severing  tube  and  ovarian  ligament  from  uterus  through  an  anterior  colpotomy. 

step  11. 

cedures  should  prevail  in  the  treatment  as  have  been  recorded  for  acute 
inflammations  of  the  uterus.  Rest  must  be  enjoined,  long-continued 
hot  vaginal  douches,  ice-bag  to  the  abdomen,  glycerin  and  ichthyol 
tampons,  free  evacuation  of  the  bowel,  and  the  maintenance  of  a  light. 


NEW-FORMATIONS  OF  THE  OVARY 


755 


nutritious  diet  should  be  prescribed  in  the  hope  that  the  inflammation 
will  subside.  If  in  the  course  of  time  pus  accumulates  in  the  ovary 
or  certain  tissue  changes  remain  which  lead  to  serious  and  persistent 
local  distress,  surgery  should  be  invoked. 


Fig.  506 


Anterior  colpotomy.  Ligature  of  the  infundibulopelvic  ligament  through  an  anterior  colpotomy. 
The  broad  ligament  is  sutured  after  the  removal  of  the  appendages  and  the  round  ligament  is  sutured 
to  the  posterior  surface  of  the  fundus.     Step  12. 


On  page  468  the  author  has  argued  for  conservatism  in  the  surgery 
of  the  tube,  and  has  stated  his  reasons  therefor.  In  the  surgery  of 
the  ovary  there  is  a  much  wider  scope  for  conservatism.  The  following 
lesions  are  amenable  to  conservative  treatment: 


756       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

Periovaritis. — When  adhesions  bind  the  ovary  to  neighboring  tissues 
and  the  structure  of  the  ovary  is  not  impaired,  the  simple  severing  of 
the  adhesions  is  all  that  is  required.  If  the  surface  of  the  ovary  presents 
a  raw  surface  after  the  breaking  up  of  the  adhesions,  the  author  generally 
lightly  chars  the  surface  with  the  thermocautery  to  prevent  the  refor- 
mation of  adhesions.     Not  uncommonly  there  is  more  or  less  cystic 

Fig.  507 


Posterior  colpotomy  for  inspection  and  possible  operation  upon  the  uterine  appendages.  The 
vaginal  wall  is  grasped  by  tissue  forceps  at  its  juncture  with  the  posterior  wall  of  the  cervix.  A  trans- 
verse incision  is  made  with  scissors  through  the  vaginal  wall  and  peritoneum.    Step  1. 


degeneration  of  the  ovaries,  in  which  event  a  resection  of  the  ovary 
will  remove  all  or  the  greater  part  of  the  raw  surface  created  by  the 
breaking  up  of  the  adhesions. 

In  breaking  frail  adhesions  little  difficulty  will  be  experienced.  When 
the  adhesions  are  extensive  it  may  be  necessary  to  resort  to  the  scissors. 
With  the  ovary  firmly  embedded  in  adhesions  it  is  best  to  proceed 


NEW-FORMATIONS  OF  THE  OVARY 


Ihl 


from  below  upward.    In  this  manner  the  ovary  is  rollerl  upon  its  hilum 
as  an  axis. 

Cystic  Degeneration. — ^Multiple  Graafian  and  corpus  luteum  cysts 
may  be  removed,  either  by  resection  with  the  knife  or  by  cauterizing. 
From  the  author's  microscopic  and  clinical   studies  of  ISO  cases  of 

Fig.  .508 


Posterior  colpotomy.     With  the  cervix  drawn  forward  and  upward  and  the  margins  of  the  incision 
held  apart,  the  posterior  wall  of  the  uterus  is  brought  to  view.     Step  2. 


cystic  degeneration  of  the  ovaries  which  required  operative  interference/ 
the  author  concluded  his  report  by  asking  the  question,  "  Should  we 
operate  on  cystic  ovaries?"  In  answer  to  this  question,  he  said  that 
the  frequent  occurrence  of  symptoms  referable  to  the  ovaries  justifies 

1  Trans.  Chicago  Gyn.  Soc,  1903-4. 


758       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

the  practice  of  resecting  or  cauterizing  and  sometimes  of  removing 
the  ovary,  when  the  abdomen  has  been  opened  for  the  relief  of  other 
pelvic  lesions.  This  should  be  the  rule  when  the  performance  would 
not  entail  greater  risk  to  the  patient.  Such  a  practice  will  frequently 
contribute  to  the  complete  relief  of  the  patient. 

Fig.  509 


Posterior  colpotomj'.     The  peritoneum  is  stitched  to  the  incised  vaginal  wall  with  interrupted  catgut 

sutures.     Step  3. 


The  question  of  operating  upon  uncomplicated  cases  of  cystic 
ovaries  is  more  debatable.  The  lesion  frequently  has  absolutely  no 
clinical  entity,  and  therefore,  should  not  be  interfered  with.  On 
the  other  hand,  in  a  definite  proportion  of  cases  there  is  sufficient  local 
discomfort  to  justify  surgical  interference. 

When  pain,  tenderness,  and  dysmenorrhea  are  complained  of  the 
surgeon  must  first  satisfy  himself  that  these  complaints  are  not  the 


NEW-FORMATIONS  OF  THE  OVARY 


759 


result  of  associated  lesions  or  the  expression  of   a   general   nervous 
disorder. 

I  believe  in  the  resection  and  even  in  the  complete  removal  of 
uncomplicated  cystic  ovaries,  but  only  when  local  discomfort,  which 
is  the  direct  result  of  the  lesion,  justifies  the  sacrifice  of  part  or  all  of 
the  ovaries.    Such  cases  are  not  common. 


Fig.  510 


Posterior  colpotomy.    The  body  of  the  uterus  is  drami  through  the  incision  by  means  of  a  tenaculum 

forceps.     Step  4. 

The  above  conclusions  were  written  in  1903,  and  since  that  time, 
increasing  experience  has  served  to  confirm  all  that  was  then  stated. 

The  author  is  in  full  accord  with  Dr.  Edward  Reynolds,  who  does 
not  operate  on  these  cases  merely  because  they  exist,  but  operates 
for   the   relief    of    distressing   symptoms    (dysmenorrhea,    catamemal 


760       TUMORS  OF  THE  PELVIC  LIGAMENTS  AND  OVARIES 

depression)  referable  to  the  ovaries;  he  beHeves  that  these  symptoms 
will  be  relieved  in  the  majority  of  cases  by  resection  of  the  ovaries. 
It  is  not  often  that  the  abdomen  is  opened  for  the  simple  correction 
of  this  condition.  There  are  other  lesions,  such  as  retroversion,  uterine 
fibroids,  and  chronic  metritis,  which  commonly  accompany  the  condition 
and  call  for  correction. 


Fig.  511 


Posterior  colpotomy.  The  fundus  and  appendages  are  delivered  through  the  posterior  incision  and 
the  uterine  appendages  inspected.  The  same  procedures  may  be  carried  out  as  in  anterior  colpotomy. 
Step  5.     (See  Figs.  499,  500,  501,  503,  and  504.) 

Technic  of  Excision  of  Part  of  the  Ovary. — Long  hemostatic  forceps 
are  made  to  grasp  the  ovarian  ligament  on  the  one  side  of  the  ovary 
and  the  suspensory  ligament  on  the  other.  When  possible  the  ovary 
is  delivered  through  the  abdominal  incision  and  a  gauze  pad  is  tucked 


NEW-FORMATIONS  OF  THE  OVARY  761 

underneath  the  ovary  and  tube.  The  portion  to  be  resected  is  grasped 
with  rat-tooth  forceps  and  a  wedge-shaped  incision  is  made  to  embrace 
the  cystic  portion  of  the  ovary.  Such  cysts  as  remain  after  the  excision 
are  punctured  with  the  knife  and  the  secreting  epithehum  destroyed 
by  scarification.  If  the  excision  is  deep,  it  is  well  to  bury  a  row  of  sutures 
and  then  to  continue  with  a  running  suture  the  closure  of  the  wedge. 
No.  1  plain  sterile  catgut  will  suffice  for  the  purpose. 

Two  points  are  of  special  importance  in  resecting  the  ovary:  (1) 
The  ovarian  blood  supply  must  not  be  interfered  with,  and  (2)  the 
ovary  is  to  be  secured  in  its  normal  position.  If  these  two  conditions 
are  met  there  will  be  little  trouble  from  the  recurrence  of  cystic  degen- 
eration. The  cut  surfaces  must  be  accurately  coapted  and  the  ovary 
not  handled  roughly  in  order  to  avoid  postoperative  adhesions.  Abso- 
lute hemostasis  should  be  secured. 

Compensatory  hypertrophy  undoubtedly  occurs  in  the  resected 
ovary. 

When  the  entire  ovary  is  to  be  removed,  because  of  the  complete 
degeneration  of  its  structure,  the  organ  is  severed  from  its  hilum  by  a 
wedge-shaped  incision;  this  is  closed  by  a  running  catgut  suture.  Careful 
coaptation  of  the  tissues  is  essential  in  the  prevention  of  postoperative 
adhesions  and  hemorrhage. 

Under  no  circumstances  should  both  ovaries  be  sacrificed  in  the 
period  of  sexual  maturity.  At  least  part  or  all  of  one  ovary  should 
be  conserved. 

Ovarian  Abscesses. — Ovarian  abscesses  are  rarely  treated  conserva- 
tively except  in  vaginal  drainage.  It  would  seem  hazardous  to  clean 
out  an  abscess  cavity  in  the  ovary  and  suture  the  cavity,  leaving  the 
ovary  in  situ.  It  is,  however,  occasionally  possible  to  conserve  a  portion 
of  the  ovary  which  has  not  directly  formed  a  part  of  the  abscess  wall. 

When  malignancy  exists  in  an  ovary  it  is  not  only  imperative  that 
the  entire  ovary  should  be  sacrificed,  but  because  of  the  frequency 
with  which  the  disease  occurs  in  both  ovaries,  the  slightest  suspicion 
of  the  existence  of  the  lesion  in  the  opposite  side  would  justify  the 
sacrifice  of  the  organ. 


CHAPTER  XXX 


TRAUMATIC  INJURIES  OF  THE   GENITAL  ORGANS 


\Y0UNDS    OF    THE    VuLVA   AND    PEL%aC 

Floor 
colpoperineorrhaphy 

External  Superficial  Tear 
Internal     Tear     and     Combined 

External     and   Internal    Tears 

(Incomplete  Laceration  of  the 

Perineum) 
Late     Repair     of     a     Complete 

Rupture    of    the    Rectovaginal 

Septum 
Repair     of     the     Sphincter     Ani 

Muscle 


Relaxed  Outlet  of  the  Recto- 
vaginal Septum 

After-treatment  of  Plastic  Oper- 
ations on  the  Pelvic  Floor 

Wounds  of  the  Vagina 

Acquired  .  Stenosis  and  Atresia  of 
THE  Vagina 

Wounds  of  the  Cervix 

Immediate  Rep.ur  of  a  Lacerated 
Cervix 

Amputation  of  the  Cervix 

Perforating  Wounds  of  the  Uterus 


WOUNDS  OF  THE  VXJLVA  AND  PELVIC  FLOOR 


Etiology. — The  vulva  is  a  common  seat  of  injury,  and  such  injuries 
are  often  serious  because  of  the  great  liability  to  hemorrhage  and 
infection. 

1.  Direct  Violence. — The  vulva  may  sustain  direct  injury  from  a 
blow,  from  falling  astride  of  an  object,  from  surgical  interference,  and 
from  violent  intercourse.  Such  injuries  result  not  only  in  contusions 
and  lacerations  of  the  soft  tissues,  but  in  hemorrhage  and  infection, 
which  may  prove  fatal.  The  soft  tissues  are  forced  against  the  sharp 
edge  of  the  pubis  and  ischium,  so  that  extensive  lacerations  are  readily 
produced. 

2.  Labor. — The  most  frequent  cause  of  injury  to  the  vulva  is  found 
in  labor.  The  presenting  part  of  the  child  and  the  application  of 
forceps  and  other  instruments  lead  to  contusions  of  the  labia  and 
to  lacerations  of  the  perineum,  nymphae,  and  vestibule. 

Symptoms. — The  symptoms  complained  of  are  pain,  hemorrhage, 
and  impaired  functions. 

Pain. — Pain  is  of  short  duration.  The  sharp,  acute  pain  soon  gives 
way  to  smarting.  If  the  parts  are  kept  at  rest  and  are  not  infected 
the  pain  should  wholly  subside. 

Hemorrhage. — The  vulvar  tissues  are  vascular,  so  that  lacerated 
wounds  may  lead  to  free  and  even  fatal  hemorrhage. 

Impaired  Functions. ^The  swelling  of  the  tissues  which  follows  upon 
injuries  to  the  vulva  may  be  extensive,  and  may  interfere  with  urination 
and  defecation.    Injuries  to  the  perineal  body  may  be  so  extensive  as 


COLPOPERINEORRHAFHY  763 

to  lead  to  loss  of  support  to  the  vaginal  walls,  uterus,  bladder,  and 
rectum. 

Treatment. — General  treatment  may  be  required  in  event  of  shock, 
hemorrhage,  or  infection.     (See  respective  chapters.) 

Hemorrhage  can  usually  be  controlled  by  applying  a  compress  of 
sterile  gauze,  held  in  place  by  a  T-binder.  Additional  pressure  may 
be  gained  by  packing  the  vagina  with  sterile  gauze.  "When  this  does 
not  suffice  to  control  the  bleeding,  the  bloodvessels  must  be  ligated  with 
catgut. 

Contusions  are  best  treated  by  the  application  of  hot  compresses. 
Lead  water  and  laudanum  is  a  soothing  application.  If  there  is  no 
evidence  of  infection  in  the  wound,  sutures  should  be  inserted  and  a 
sterile  pad  of  gauze  placed  over  the  sutured  wound  and  held  in  place 
by  a  T-binder.  Catgut  should  be  used  in  all  deep  wounds  and  silk 
or  silkworm  gut  in  superficial  wounds.  Voluntary  urination  should 
be  encouraged  and  the  wound  douched  with  an  antiseptic  solution  after 
urinating.  WTien  the  wound  is  infected  it  is  best  to  leave  it  open  and 
drain  with  gauze  saturated  in  Wright's  solution,  and  to  apply  a  hot 
antiseptic  compress  over  the  vulva  until  the  acute  inflammatory 
reaction  has  subsided,  after  which  a  dry  sterile  pad  may  be  substituted 
for  the  hot  compress.    (For  a  discussion  of  perineal  wounds  see  below.) 


COLPOPERINEORRHAPHY 

Recent  and  late  obstetric  injuries  to  the  rectovaginal  septum  are 
classified  under  three  heads : 

1.  External  superficial  tear. 

2.  Internal  and  combined  external  and  internal  tears. 

3.  Complete  tear  of  the  rectovaginal  septum. 

External  Superficial  Tear. — All  such  injuries  should  be  repaired 
immediately  following  delivery,  but  not  having  been  repaired  at  this 
time,  they  present  no  indication  for  operative  interference  unless  they 
have  healed  with  a  tender  scar.  This  is  true  because  the  support  of 
the  uterus  and  vaginal  walls  has  not  been  weakened.  The  tear  only 
involves  the  skin  surface  and  lax  tissues  which  lie  between  the  fourchette 
and  rectum,  possibly  extending  through  the  vaginal  mucosa  for  a 
limited  distance. 

Immediate  Repair. —  Technic  of  Operation. — The  lips  of  the  tear  are 
held  apart  by  the  thumb  and  index  finger  of  the  left  hand.  The  first 
suture  is  passed  immediately  below  the  upper  angle  of  the  tear.  One 
or  two  additional  sutures  are  passed  at  intervals  of  a  half  inch  below 
this  point.  The  sutures  are  then  tied  from  above  do\\Tiward.  In  this 
manner  the  tissues  are  restored  to  their  original  position.  Care  must 
be  taken  to  avoid  tying  the  sutures  too  tight  for  fear  of  interfering 
with  the  circulation  in  the  tissues  and  predisposing  to  infection.  The 
sutures  may  be  removed  on  the  eighth  day.  The  author's  preference 
is  for  silkworm  gut. 


764 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


Late  Repair. —  Technic  of  Operation. — Tenacula  are  made  to  grasp  the 
divided  ends  of  the  carimculse.  A  third  tenaculum  grasps  the  midpoint 
of  the  scar  at  the  lower  limit.  The  scar  is  then  placed  upon  the  stretch 
by  the  assistants  making  gentle  traction  upon  the  tenacula.  In  this 
manner  a  triagular  area  of  the  scar  tissue  is  exposed  for  denudation. 


Dissection  of  the  female  perineum.  1,  glans  clitoridis;  2,  urogenital  muscle  of  trigone;  3,  inferior 
ramus  of  pubis  and  ischium;  4,  tendon  of  levator  ani  muscle;  5,  coccygeal  muscle;  6,  external  sphincter 
ani  muscle;  7,  coccyx;  8,  anus;  9,  levator  ani  muscle;  10,  internal  obturator  muscle;  11,  vagina;  12, 
urethra.    (Leipmann.) 


-  With  sharp-pointed  angular  scissors  and  rat-tooth  tissue  forceps, 
the  area  of  denudation  is  outlined  by  connecting  the  angles  of  the 
triangle  marked  by  the  tenacula.  With  a  sharp  scalpel  th,e  scar  is 
removed,  leaving  a  denuded  triangle. 

A  long  curved  needle,  threaded  with  chromic  catgut  or  silk,  is  passed 
from  a  point  ^  to  1  cm.  external  to  the  right  upper  angle  to  a  corre- 
sponding point  on  the  opposite  side  and  including  the  intervening 
tissues.    At  intervals  of  one-half  inch  similar  sutures  are  passed  from 


COLPOPERINEORRHAPH  Y 


765 


above  downward.  When  these  sutures  are  tied  the  line  of  union  is 
vertical  and  in  the  median  line.  These  sutures  are  cut  short  and  a 
dressing  of  iodoform  gauze,  with  a  pad  of  sterile  gauze,  is  applied  and 
held  in  place  by  a  T-binder. 


Fig.  513 


The  di^dded  ends  of  the  caruncular  ring  in  the  figure  are  approximated  by  tenacula.     In  this  manner 
the  extent  of  the  laceration  is  demonstrated. 


Internal  Tear  and  Combined  External  and  Internal  Tears  (Incomplete 
Laceration  of  the  Perinemn) . — Internal  tears,  in  the  absence  of  external 
tears,  are  commonly  overlooked.  They  extend  from  the  hymen  or 
fourchette  a  variable  depth  upward  and  outward  to  one  or  both  sulci. 
Such  injuries  lead  to  relaxation  of  the  pelvic  floor  and  materially 
weaken  the  support  to  the  uterus  and  vaginal  walls.  The  author 
emphasizes  the  necessity  of  close  inspection  of  the  vaginal  walls  after 
the  completion  of  labor,  and  if  found  torn,  sutures  are  to  be  inserted 
so  that  they  will  unite  the  severed  tissues.  The  perineal  body  is  often 
seen  represented  by  skin  and  connective  tissue,  there  being  no  muscular 
or  facial  structures  to  afford  the  needed  support.  This  arises  through 
failure  to  recognize  deep  internal  tears  or  through  faulty  suturing  of 


766 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


combined  internal  and  external  tears  by  passing  sutures  through  the 
skin  and  including  the  intervening  lacerated  tissues.  In  so  doing  the 
vaginal  tears  are  not  sutured. 


Fig.  514 


Complete  laceration  of  the  perineum  with  cystocele.  C,  divided  ends  of  caruncular  ring;  Sph, 
divided  ends  of  the  sphincter.  The  loss  of  the  pelvic  floor  and  the  sagging  of  the  anterior  wall  of  the 
vagina  precede  the  descent  of  the  uterus. 


Immediate  Repair. —  Technic  of  Operation. — The  patient  is  placed 
in  the  lithotomy  position  at  the  edge  of  the  bed,  or  preferably  on  an 
operating  table.  A  general  anesthetic  is  given.  The  field  of  operation 
is  prepared  by  scrubbing,  shaving,  washing  with  sterile  water,  and 
scrubbing  with  alcohol.  Sterile  towels  are  then  placed  about  the  field 
of  operation  and  the  operator  proceeds  to  place  the  sutures.  The  tear 
is  exposed  by  the  thumb  and  index  fingers  of  the  left  hand.  If  the 
tear  extends  deeply  into  the  vagina,  the  anterior  wall  of  the  vagina 
should  be  supported  by  a  retractor.  The  sutures  placed  in  the  vagina 
should  be  No.  2,  ten-day  chromic  catgut,  and  those  placed  in  the 
perineum  should  be  of  silk  or  silkworm  gut.    The  first  suture  is  passed 


COLPOPERINEORRHAPHY 


767 


Fig.  515 


Fig.  516 


Superficial  combined  internal  and  external  tear, 
showing  portion  of  tear  in  vagina  that  may  escape 
notice.     (Jewett.) 

Fig.  517 


Internal  stitches  in  position. 
Fig    518 


Internal  stitches  tied. 


Internal  stitches  tied,   external   stitches  in 
position. 


768 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


just  below  the  upper  angle  of  the  tear  in  the  vagina  and  the  successive 
sutures  are  passed  about  one-half  inch  apart  from  above  downward. 
A  short  curved,  cutting  edge  needle  is  introduced  at  a  point  about 
one-quarter  of  an  inch  from  the  margin  of  the  tear  and  is  carried  through 
the  tissues  in  the  direction  of  the  operator,  to  a  midpoint  in  the  floor 
of  the  tear,  where  it  is  brought  out  and  again  made  to  reenter  the  tissues 
at  this  point  and  come  out  at  a  point  in  the  vaginal  walls  opposite 
to  its  point  of  entrance.  In  this  second  step  the  needle  is  carried 
upward  and  away  from  the  operator.  Each  suture  should  be  tied 
when  introduced. 


Fig.  519 


Demonstrating  an  internal  laceration  of  the  pelvic  floor. 


Having  closed  the  tear  in  the  vaginal  walls  the  severed  skin  margins 
of  the  perineum  are  approximated  in  a  similar  manner  with  silk  or 
silkworm  gut. 

After-treatment. — The  patient  should  be  encouraged  to  pass  her 
urine,  after  which  the  perineum  is  douched  with  an  antiseptic  solution 
and  a  sterile  pad  applied  to  the  Vulva.  When  there  is  retention  of 
urine  the  catheter  must  be  used.  The  bowels  should  be  moved  at  the 
end  of  forty-eight  hours.  It  is  not  necessary  to  tie  the  knees.  On  the 
contrary  the  patient  should  be  permitted  to  shift  her  position  at  will. 

Late  Repair. —  Technic  of  Operation. — A  great  variety  of  operations 
have  been  devised,  all  having  more  or  less  merit.    For  want  of  space 


COLPOPERINEORRHAPH  Y 


769 


the  author  will  here  describe  but  three  operations  which  have  been 
most  satisfactory  in  his  experience : 

The  Holden  perineorrhaphy  is  based  upon  the  principle  first  advocated 
by  C.  P.  Noble  in  1897,  that  of  approximating  the  borders  of  the 
levator  ani  muscles.  The  following  is  a  quotation  from  the  original 
paper  of  Holden:^ 

"  The  area  of  denudation  is  triangular  in  shape  on  the  vaginal  surface, 
the  apex  of  the  triangle  being  from  4  to  6  cm.  from  the  outlet  in  the 
median  line.     From  this  point  the  denudation  runs  out  to  the  lower 


Fig.  520 


Repair  of  an  incomplete  laceration  of  the  perineum.     Holden's  modification  of  Noble's  operation. 
Area  of  denudation  exposing  the  separated  levator  ani  muscle.     Step  1. 

part  of  the  remains  of  the  hymen,  the  upper  and  outer  lateral  limit 
being  about  the  same  as  in  the  Emmet  operation.  The  external  denuda- 
tion is  brought  down  to  a  point  which  is  usually  just  above  the  position 
of  the  sphincter  ani.  The  limits  of  the  denudation  are  first  marked 
out  with  the  knife,  then  the  vaginal  mucosa  is  removed  with  the  Emmet 
scissors. 

"The  border  of  the  levator  ani  muscle  on  one  side  is  now  felt  by 
palpation,  with  the  finger  just  behind  the  ischiopubic  ramus. 


1  Amer.  Jour.  Obstet.,  No.  33,  vol.  lii,  p.  497. 


49 


770 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


"Under  guidance  of  the  palpating  finger  this  broad  edge  of  muscle 
is  seized  with  the  mouse-tooth  dissecting  forceps,  through  the  overlying 
fascia  and  connective  tissue,  and  is  drawn  out  toward  the  median 
line.  A  round  needle  bearing  a  silk  suture  transfixes  the  fascia  and 
muscle.  The  suture  is  not  tied.  The  ends  are  clamped,  and  it  is  used 
to  draw  the  muscle  forward  and  make  it  prominent,  when  later  in  the 
operation  it  is  necessary  to  pass  sutures  through  the  muscle.  A  second 
suture  is  next  passed  through  the  muscle  of  the  opposite  side  in  a 
similar  manner. 

Fig.  521 


Repair  ot  an  incomplete  laceration  of  the  perineum.  Apex  of  denuded  area  closed  with  interrupted 
chromic  catgut  sutures.  Figure-of-eight  sutures  of  chromic  catgut  or  silkworm  gut  passed  through 
the  levator  ani  muscles  and  overlying  vaginal  walls  and  fascial  structures.     Step  2. 


"The  denudation  of  vaginal  mucosa  should,  of  course,  extend  high 
enough  on  the  lateral  walls  of  the  vagina  to  allow  the  muscles  to  be 
brought  together  easily  in  the  median  line. 

"Two  external  sutures  of  silkworm  gut  are  now  introduced,  as 
shown  in  Fig.  520.  Each  suture  passes  first  through  skin^  and  sub- 
cutaneous tissue,  through  the  levator  ani  on  the  same  side,  then  through 
the  opposite  muscle  from  before  backward,  and  finally  out  through 
the  skin  and  subcutaneous  tissue  on  that  side.  When  the  needle  is 
passed  through  the  levator  ani,  an  assistant  pulls  on  the  silk  traction 
suture  which  has  previously  been  passed  through  the  muscle,  making 


COLPOPERINEORRHAPH  Y 


111 


it  stand  out,  and  a  deep  bite  can  be  taken,  passing  through  the  entire 
muscle. 

"The  lowest  suture  is  put  near  the  rectum,  the  left  forefinger  of  the 
operator  pushing  the  rectum  down  so  that  it  is  not  injured.  The  second 
suture  is  placed  about  2  cm.  above  the  first  suture.  When  these  two 
sutures  are  drawn  tight,  the  borders  of  the  two  muscles  are  closely 
approximated,  as  are  also  the  edges  of  the  skin  incision.  The  muscles 
are  also  held  firmly  against  the  skin  and  subcutaneous  tissue. 

Fig.  522 


Repair  of  an  incomplete  laceration  of  the  perineum.     Figure-of-eight  sutures  drawn  taut,  thereby 
approximating  the  levator  ani  muscles.     Step  3. 


"The  silkworm-gut  sutures  are  not  tied  until  after  the  internal 
stitches  are  placed  and  tied.  The  temporary  traction  sutures  through 
the  muscles  may  now  be  removed  if  desired,  as  the  muscles  are  well 
splinted  out  and  rendered  sufficiently  prominent  by  the  silkworm-gut 
sutures.  The  first  internal  stitches  are  of  plain  catgut  and  begin  at 
the  apex  of  the  triangle.  Three  or  four  stitches  are  usually  taken, 
uniting  the  cut  edges  of  the  mucosa  and  catching  enough  of  the  denuded 
surface  between  to  prevent  leaving  any  dead  space  and  to  stop  all 
bleeding. 

"The  figure-of-eight  stitch  which  is  next  placed  is  best  understood 
by  referring  to  Fig.  521. 


772 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


"Formalin  or  chromic  catgut  is  used.  The  stitch  starts  on  the 
right-hand  side,  passes  through  mucosa  and  underlying  tissue  to  the 
posterior  surface  of  the  muscle.  Without  touching  the  muscle  of  that 
side  it  is  carried  to  the  opposite  side  and  pierces  that  muscle  from 


Fig.  523 


Repair  of  incomplete  laceration  of  the  perineum.  Figure-of-eight  sutures  tied  and  two  interrupted 
sutures  of  silkworm  gut  or  chromic  catgut  approximating  the  superficial  structures  of  the  perineum. 
Operation  complete.     Step  4. 

Fig.  524 


Mayo  dissecting  scissors. 


behind  forward.  Then  it  passes  to  the  anterior  surface  of  the  muscle 
on  the  first  side  and  passes  through  that  from  before  backward.  Finally 
passing  to  the  second  side  it  is  brought  out  through  the  mucosa  and 
underlying  tissue  in  the  same  way  as  it  entered  on  the  first  side.    Two 


COLPOPERINEORRHAPH  Y 


773 


such  stitches  are  inserted.  The  first  one  pierces  the  muscles  between 
the  two  silkworm-gut  sutures,  the  second  goes  through  the  muscles 
above  the  uppermost  silkworm-gut  stitch. 

"  By  tying  these  two  figure-of-eight  sutures  the  borders  of  the  levator 
ani  muscles  are  brought  together,  the  cut  edges  of  the  vaginal  mucosa 
are  neatly  approximated,  and  the  mucosa  as  a  whole  is  bound  down 
firmly  to  the  posterior  surface  of  the  muscles.  A  muscular  wall  is 
built  up  and  the  posterior  portion  covered  with  mucosa;  the  anterior 
surface  is  as  yet  bare. 


Fig.  525 


Emmet's  angular  uterine  scissors. 


"  By  tying  the  silkworm-gut  sutures  the  anterior  part  of  the  muscular 
perineal  wall  is  covered  by  skin  and  subcutaneous  tissue,  the  muscles 
are  still  more  closely  approximated,  and  are  firmly  bound  to  their 
covering  of  subcutaneous  tissue  and  skin  in  front.  One  or  two  superficial 
stitches  of  plain  catgut  are  sometimes  necessary  to  approximate  the 
skin  or  mucosa  at  the  upper  part  of  the  wound." 

The  advantages  of  this  operation  are: 

1.  Simplicity. 

2.  Little  loss  of  blood. 

3.  No  dead  spaces  left. 

4.  No  buried  sutures  which  are  liable  to  infection. 

5.  The  rectocele  is  pushed  back  of  the  perineal  body. 


774  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

The  Emmet  Operation  for  Incomplete  Laceration  of  the  Perineum. — 
This  operation,  while  less  simple  in  execution,  gives  most  excellent 
results  and  will  probably  remain  as  a  classical  procedure. 

The  limits  of  denudation  are  first  defined  by  grasping  either  end 
of  the  divided  camnculEe  with  tenacula  and  approximating  them  in 
the  median  line  (Fig.  515).  These  points  of  fixation  mark  the  upper 
lateral  limits  of  the  area  to  be  denuded. 


Fig.  526 


Fig.  527 


';j|^^ 


Repair  of  an  incomplete  laceration  of  the 
perineiim.  (Emmet.)  Area  of  denudation, 
with  suture  of  chromic  catgut  passed  through 
the  lateral  sulcus.     Step  1. 


Repair  of  an  incomplete  laceration  of  the 
perineum.  Right  lateral  sulcus  closed  with 
chromic  catgut  sutures.     Step  2. 


A  third  tenaculum  grasps  the  crest  of  the  rectocele  in  the  median 
line  and  with  it  traction  is  made  do^Tiward,  while  the  assistants  retract 
the  lateral  angles  outward.  In  this  manner  the  three  angles  of  the 
triangle  of  denudation  are  outlined. 

The  process  of  denudation  is  then  continued  by  first  connecting 
these  three  angles,  using  a  sharp  scalpel  and  cutting  through  the  vaginal 
mucosa.  The  bloody  lines  clearly  indicate  the  outlines  of  the  triangle, 
which  should  now  be  denuded  with  angular  scissors.  The  central 
tenaculum  and  one  of  the  lateral  tenacula  are  drawn  downward  and 
outward,  thereby  exposing  one  of  the  vaginal  sulci.  The  upper  limit 
of  the  sulcus  marks  the  extent  of  the  area  of  denudation,  and  from  this 


COLPOPERINEORRHAPH  Y 


775 


point  the  -knife  is  drawn  downward  and  outward  to  the  lateral  ten- 
aculum, and  again  downward  to  the  tenaculum  at  the  crest  of  the 
rectocele.    The  intervening  space  is  denuded. 

A  similar  process  is  carried  out  on  the  other  side,  thus  forming  two 
triangular  areas  of  denudation,  one  on  either  side  of  the  rectocele. 

A  triangular  undenuded  area  remains  between  these  two  triangles, 
as  shown  in  Fig.  526. 


Fig.  528 


Repair  of  an  incomplete  laceration  of  the  perineum.      Both  lateral  sulci  closed  by  sutures  of  chromic 
catgut  and  crown  stitch  of  silkworm-gut  placed.      Step  3. 


All  scar  tissue  below  is  then  dissected  off  with  angular  scissors. 
This  dissection  is  done  by  sweeping  in  a  semicircle  around  the  posterior 
wall. 

The  tissues  are  now  so  approximated  with  sutures  as  to  cover  all 
denuded  surfaces  and  to  restore  the  perineal  structures  to  their  original 
positions  and  functions. 

From  the  apex  of  the  lateral  triangles,  No.  2  ten-day  chromic  catgut 
is  placed  and  the  lateral  margins  of  the  triangles  united  as  seen  in 
Fig.  527. 

The  crown  stitch  of  silkworm  gut  is  next  passed  from  one  end  of  the 
divided  carunculse  downward  and  inward  to  the  apex  of  the  undenuded 
triangle,  then  upward  and  outward  to  the  other  end  of  the  divided 
carunculee.  This  suture  is  tied,  and  by  so  doing  the  outlet  is  restored 
(Fig.  528  and  529). 


776 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


From  this  point  downward  interrupted  silkworm-gut  sutures  are 
passed  and  tied,  thereby  completing  the  operation  (Fig.  530). 

Tait's .  Operation. — The  following  description  of  Tait's  operation  is 
given  by  George  H.  Noble  :^ 

"In  the  H-operation  he  made  a  'real  flap  of  mucous  membrane.' 
There  seems  to  be  some  discrepancy  in  the  details  of  the  various  authors 
describing  these  operations,  and  as  Tait  has  complained  of  'most 
inextricable'  confusion  arising  from  this  source,  the  following  account 
is  condensed  from  McKay's  description,  to  which  the  originator  gave 
his  unqualified  endorsement. 


Fig.  529 


Fig.  530 


Emmet's  operation.  Repair  of  an  incomplete  laceration 
of  the  perineum.  Traction  made  upon  the  crown  stitch  to 
demonstrate  the  effect  of  the  operation.     Step  4. 


Emmet's  operation.  Repair  of  an 
incomplete  laceration  of  the  perineum. 
Stitches  tied.  Operation  completed. 
Step  5. 


~  "First  Step. — With  two  fingers  in  the  rectum  as  a  guide,  a  short 
vertical  nick  is  made  in  the  margin  of  skin  and  mucous  membrane  in 
the  medial  line  just  in  front  of  the  anus  at  P,  Fig.  531.  At  this  point 
the  sharp  point  of  the  scissors  is  forced  three-fourths  of  an  inch  into 
the  tissue  and  an  incision  is  made  along  the  junction  of  skin  and  mucous 
membrane,  to  the  right  side  of  the  vaginal  orifice  to  a  point  marked  R, 

1  Bovee's  Practice  of  Gynecology,  first  edition,  p.  210. 


COLPOPERIXEORRHAPH  Y 


111 


just  posterior  to  the  inferior  extremity  of  the  labium  minus.     The 
opposite  side  is  incised  in  the  same  wa}-  to  the  point  marked  L. 


Fig.  531 


Tait's  operation  for  incomplete  tear  of  the  perineiim:    L  P  R,  line  of  incision;  P  V  F,  posterior  vaginal 

flap;  P,  perineum. 


"  Second  Step. — The  raw  V-shaped  surface  made  by  the  incision  is 
slightly  increased  by  carefully  snipping  along  the  edges  of  the  imperfect 


778  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

l&nd!ZJ  T  t"^  ''''"'''  "T  ^"^  ^°^^  ''  i*  i^  -t'  widening 
the  denudation.    Tait  says,  most  emphatically,  that  this  surface  (i?  L  P) 


Fig.  532 


AM 


Same  as  Fig.  531,  with  sutures  introduced. 

S/tctol'"''  °"^'  ^"^  '^  "'<^°°^  -i"-  --  tl^-  --ke  the 


COLPOPERINEORRHAPHY  779 

"  Third  Step. — A  needle  on  a  handle  is  used,  the  point  entering  just 
inside  the  skin  margin  at  1  (Fig.  532) ;  emerges  in  the  raw  surface  near 
the  median  line  at  2,  reenters  a  corresponding  point  at  3,  and  emerges 
just  inside  the  skin  edge  at  4.  The  needle  is  then  threaded  with  silk- 
worm gut,  and  withdrawal  pulls  the  suture  into  place.  The 
second  suture  is  introduced  in  the  same  way,  entering  the  needle  at 
5,  out  at  6,  in  again  at  7,  and  out  at  8;  thus,  the  two  lower  sutures  are 
introduced  with  one  sweep  of  the  needle;  the  two  upper  ones  require 
two  passes  of  the  needle.  The  needle  is  inserted  at  9,  emerges  at  10, 
is  threaded  and  withdrawn.  It  penetrates  again  at  12,  emerges  at  11, 
is  threaded  with  the  other  end  of  the  suture,  which  is  drawn  across 
in  front  of  the  posterior  vaginal  flap,  and  out  at  point  of  entry.  The 
last  and  topmost  suture  is  passed  in  the  same  way  at  points  marked 
by  the  figures  13,  14,  15,  and  16.  Each  end  of  the  sutures  is  secured 
with  catch  forceps  to  prevent  accidental  withdrawal. 

"Fourth  Step.— The  forceps  holding  the  ends  of  the  upper  sutures 
BCD  are  turned  up  over  the  mons  and  held  by  an  assistant,  and  the 
wound  irrigated,  sponged,  and  spurting  vessels  secured.  An  assistant 
then  presses  the  buttocks  together  as  the  lower  suture  A  is  gently 
drawn  upon  and  tied.  The  second  suture  D  is  tied  in  the  same  way. 
The  assistant  presses  the  sides  R  L  strongly  together  while  the  operator 
ties  sutures  B  and  C.  Should  too  much  cutting  be  done  in  the  process 
of  dissection  and  a  'real  flap'  be  formed,  it  is  left  to  take  care  of  itself." 

Immediate  Repair  of  a  Complete  Laceration  of  the  Perineum, — A 
complete  tear  of  the  perineum  starts  at  the  fourchette  and  extends 
back  in  the  median  line  of  the  perineum,  through  the  sphincter  ani 
muscle,  and  involves  more  or  less  of  the  rectovaginal  septum.  Because 
of  the  resulting  incontinence  of  feces,  a  complete  laceration  should  be 
repaired  at  the  completion  of  labor.  However,  Hearst  advocates 
waiting  until  the  tenth  day  of  the  puerperium,  believing  that  he  can 
be  more  certain  of  getting  good  results. 

Technic  of  Operation. — A  general  anesthetic  is  given  and  the  patient 
placed  in  the  lithotomy  position.  The  field  of  operation  is  prepared 
in  the  usual  manner.  The  first  step  is  to  find  the  divided  ends  of  the 
sphincter  muscle  and  approximate  them.  If  the  rectovaginal  septum 
is  torn  above  the  sphincter,  the  margins  of  the  rectal  wall  are  first 
approximated  with  buried  chromic  catgut  sutures  No.  2.  The  sutures 
are  placed  at  intervals  of  one-fourth  of  an  inch  until  the  sphincter 
muscle  is  reached.  All  sutures  are  introduced  on  the  rectal  side  of 
the  rupture  and  should  penetrate  the  septum  deeply  enough  to  insure 
a  firm  hold.  Next  the  divided  ends  of  the  sphincter  muscle  are  approxi- 
mated by  two  chromic  catgut  sutures,  taking  care  that  the  sutures 
are  not  tied  too  tightly.  It  is  well  to  reinforce  the  catgut  sutures  by 
one  or  two  silkworm-gut  sutures.  From  this  point  on  the  operation 
is  similar  to  that  described  above  under  Immediate  Repair  of  an 
Incomplete  Laceration. 

After-treatment. — The  perineum  should  be  protected  by  a  sterile 
pad  of  surgical  gauze  and  held  in  place  by  a  T-binder.    The  patient 


780  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

should  be  encouraged  to  urinate,  and  only  when  this  is  impossible  should 
the  catheter  be  passed.     After  urinating,  the  vulva  should  be  douched 


Fig.  533 


Fig.  534 


#    Ij'^ 


Complete  tear;  closing  the  rent  in  the  bowel. 


Deep  interrupted,  lifting  sutures  in  position. 


Fig.  535 


Fig.  536 


All   sutures  laid;   vaginal   sutures   tied. 


Internal  and  external  sutures  tied. 


with  an  antiseptic  solution,  such  as  a  1  per  cent,  lysol  solution.    When 
possible  the  bowels  should  be  locked  for  at  least  four  days,  and  the 


COLPOPERINEORRHAPH  Y 


781 


author  has  been  able  to  make  the  patient  comfortable  for  at  least 
eight  days  before  opening  the  bowels.  To  open  the  bowels  two  ounces 
of  castor  oil  should  be  given,  this  to  be  followed  in  four  to  six  hours 
with  an  enema  of  sweet  oil.  It  is  best  for  the  surgeon  or  a  competent 
assistant  to  give  the  enema,  rather  than  to  trust  it  to  a  nurse,  for  fear 
that  the  rectal  tube  may  disturb  the  sutures.     The  patient  should 


Fig.  537 


Fig.  538 


lliW\ 


Emmet's  operation.  Eupture  of  the 
rectovaginal  septum.  Complete  lacera- 
tion of  the  perineum.  Area  of  denu 
dation.  Ends  of  divided  sphincter 
•muscle  exposed.     Step  1. 


Emmet's  operation.  Rupture  of  the  rectovaginal 
septum.  Complete  laceration  of  the  perineum.  Linen 
sutures  transfix  the  di\'ided  ends  of  the  sphincter 
muscle.     Step  2. 


remain  in  bed  two  weeks.  The  diet  should  be  light.  Antiseptic  vaginal 
douches  should  be  given  daily  after  the  seventh  day.  Close  inspection 
should  be  kept  of  the  stitches,  and  if  the  tissues  appear  irritated,  the 
author  generally  elevates  the  hips  on  pillows  at  the  foot  of  the  bed  and 
keeps  a  pool  of  lysol  or  creolin  solution  (0.5  per  cent.)  in  the  vagina 
and  a  wet  antiseptic  pad  over  the  perineum.    In  this  way  he  succeeds 


782 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


in  averting  a  failure  to  get  union.      The  silkworm-gut  sutures  are 
removed  on  the  tenth  day  of  the  operation. 

Late  Repair  of  a  Complete  Rupture  of  the  Rectovaginal  Septum. — 
Evtmet's  Operation  (Modified  by  Kelly). — Step  1. — An  incision  is 
made  across  the  septum  at  the  junction  of  the  rectal  and  vaginal 
mucosa  and  is  carried  to   a  point   above  and  beyond  the  sphincter 


Fig.  539 


Fig.  540 


Emmet's  operation.  Rupture  of  the 
rectovaginal  septum.  Complete  lacera- 
tion of  the  perineum.  Chromic  catgut 
sutures  are  passed  on  either  side  of  the 
rectocele,  thereby  approximating  the 
margins  of  the  denuded  areas  above. 
Step  3. 


Emmet's  operation.  Rupture  of  the  rectovaginal 
septum.  Complete  laceration  of  the  perineum. 
Passing  of  the  crown  stitch  of  linen  or  silkworm  gut. 

Step  4. 


ends.  The  operation  proceeds  as  in  an  ordinary  relaxed  vaginal  outlet 
(Fig.  540).  With  the  area  of  denudation  completed  to  form  bilateral 
triangles  in  the  sulci  and  a  tongue  of  undenuded  tissue  intervening 
between  the  denuded  sulci,  the  operator  proceeds  to  expose  the  severed 
ends  of  the  sphincter  muscles. 


COLPOPERINEORRHA  PH  Y 


783 


Fig.  541 


Step  2. — The  index  finger  of  the  left  hand  is  inserted  into  the  rectum 
and  the  septum  drawn  gently  forward.  The  internal  sphincter  muscle 
is  carefully  dissected  and  its  ends  liberated.  In  exposing  the  sphincter 
ends  a  flap  of  undenuded  tissue  is  formed  which  serves  to  protect  the 
wound  from  the  rectal  surface.  To 
prevent  the  leaving  of  a  dead  space 
in  the  centre  of  the  septum,  three 
or  four  figure-of-8  chromic  catgut 
sutures  are  passed,  first  through 
the  fibers  of  the  sphincter  muscle, 
next  to  the  opposite  side,  and 
from  this  point  to  the  tissues  in 
the  septum  at  a  point  somewhat 
above  the  sphincter.  The  suture 
is  then  carried  to  the  first  side, 
where  it  passes  through  corre- 
sponding areas  of  tissue  and  is 
brought  through  the  internal 
sphincter  at  the  point  of  entrance. 
This  suture  will  be  found  buried 
when  the  operation  is  complete. 
Two  or  three  additional  sutures 
are  passed  in  a  similar  manner, 
and  when  brought  together  in  the 
middle  line  the  dead  space  is 
effectually  obliterated. 

Step  3. — The  margins  of  the 
triangles  are  next  approximated 
with  chromic  catgut  and  the 
perineal  wound  is  closed  with 
interrupted  silkworm-gut  sutures. 

Step  4. — The  apron  of  tissue 
protruding  from  the  rectum  is 
transfixed  by  silkworm-gut  sutures, 

with  the  ends   left   long   and  fixed  to   the  buttocks   by   a   strip   of 
adhesive  plaster,  as  suggested  by  Kelly. 

Taifs  Flap-splitting  Operaiion  {" H  Operation"). — George  H.  Noble^ 
gives  the  following  abstract  of  McKay's  description  of  Tait's  operation 
for  complete  laceration  of  the  perineum.  The  description  of  McKay 
is  approved  by  Tait: 

"Step  1. — The  scissors  enter  at  L'  (Fig.  542)  (sphincter  dimple  of 
Emmet)  to  a  depth  of  half  an  inch,  then  follow  the  edge  of  the  recto- 
vaginal septum  to  the  opposite  sphincter,  dimple  R'.  From  these 
two  points  incisions  are  made  in  an  upward  direction  along  the  muco- 
cutaneous margin  to  the  original  site  of  the  posterior  commissure 
{PC  and  P'C).    Then  an  incision  is  made  on  each  side,  beginning 


Emmet's  operation.  Rupture  of  the  recto- 
vaginal septum.  Complete  laceration  of  the 
perineum.  All  sutures  tied.  Operation  com- 
pleted.    Step  5. 


1  Bovee's  Practice  of  Gj^necology,  p.  214. 


784 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


at  the  sphincter  dimple,  cutting  downward  and  outward  to  PI  and 
PT.  These  should  be  made  sufficiently  deep  to  expose  the  ends  of 
the  sphincter  muscles. 


Fm.  542 


Tait's  operation  for  complete  tear  of  perineum:  P  C  L'  and  P'  C  R',  lateral  incisions;  L'  R',  inci- 
sion of  rectovaginal  septum;  L'  P  I,  left  posterior  incision;  R'  P'  I',  right  posterior  incision;  A  N,  anus 
R  V  S,  rectovaginal  septum. 


COLPOPERINEORRHAPHY 


785 


Fig.  513 


Insertion  of  sutures  in  Tait's  operation  for  complete  laceration  of  the  perineum. 


50 


786  TRAUMATIC  IX  J  CRIES  OF  THE  GEXITAL  ORGAXS 

"Step  2. — The  posterior  vaginal  flap  R.  VF.  L  Fig.  543)  forms  a 
W-shaped  surface  which  is  increased  by  further  dissection  of  the  flap, 
snipping  underneath  as  it  is  held  up  until  a  "fairly  large  surface,  shaped 
like  a  letter  H,"  is  formed. 

''Step  3. — Two  hooks  are  inserted  into  each  flap,  the  rectal  and 
vaginal;  the  former  is  held  up  out  of  the  way  while  the  latter  is  drawn 
do"«Tiward  in  the  direction  of  the  anus,  making  as  it  were  a  rectal  flap. 
The  sutures  are  placed  in  two  passes  of  the  needle.  It  enters  the 
raw  surface  at  a  point  marked  1  in  the  angle  of  the  extremity  of  the 
posterior  incision  PI  (on  patient's  left),  just  inside  of  the  edge  of  the 
skin,  emerges  in  the  raw  sm^ace  near  the  median  line  at  2,  crosses 
just  over  this  line  to  3,  when  it  again  enters  the  raw  siu"face,  emerging 
at  4.  The  needle  is  then  threaded,  and  on  being  withdrawn  it  pulls 
the  suture  into  place  and  its  ends  are  secured  with  a  catch  forceps. 
The  other  sutures  are  introduced  in  the  same  way:  for  instance,  for 
suture  B  the  needle  enters  at  5,  out  at  6.  in  at  7.  and  emerges  at  8. 

"Step  4. — The  forceps  holding  the  three  upper  sutm-es  i  B,  C\  D)  are 
turned  over  the  mons  and  held  by  an  assistant.  The  field  of  operation 
is  then  irrigated,  sponged,  and  spurting  vessels  secured.  An  assistant 
presses  the  buttocks  together  as  the  lower  suture  A  is  gently  drawn 
upon  and  tied,  while  another  assistant  draws  downward  the  rectal 
flap.  Each  sutiure  is  tied  in  the  same  way  from  below  upward.  The 
vaginal  flap  is  left  to  find  its  own  place  against  the  vaginal  surface 
of  the  newly  made  perineimi,  to  which  it  becomes  adherent." 


REPAIR  OF  THE   SPHINCTER   ANI  MUSCLE 

The  sphincter  ani  muscle  may  be  torn  without  injury  to  the  structures 
h"ing  above.  Kelly's  operation  for  this  condition  consists  in  making 
a  semicircular  incision  around  the  anterior  margin  of  the  anus  just 
outside  the  border  of  the  sphincter.  The  skin  is  deflected  outward. 
The  di\'ided  ends  of  the  sphincter  are  sought,  and  in  the  search  it  may 
be  necessary  to  extend  the  incision.  These  ends  are  liberated  a  sufficient 
distance  to  permit  of  their  approximation  without  undue  tension.  The 
ends  of  the  muscles  are  united  with  three  buried  catgut  sutures,  and 
the  skin  is  made  to  cover  the  muscle  by  the  insertion  of  silk  sutures. 

A  tension  suture  of  silkworm  gut  is  passed  through  the  skin  to  the 
outer  limit  of  the  incision  and  tranfixes  the  sphincter  muscle  external 
to  the  catgut  sutures,  then  passes  out  from  the  skin  surface  at  a  point 
corresponding  to  its  entrance.  This  is  placed  before  the  skin  is 
sutured,  and  is  tied  after  the  skin  is  united. 


RELAXED  OUTLET  OF  THE  RECTOVAGINAL  SEPTUM 

The  supporting  structiu-es  of  the  peMc  floor  and  vaginal  walls  may 
be  so  stretched  by  repeated  childbearing  as  to  aff'ord  little  support 


RELAXED  OUTLET  OF   THE  RECTOVAGINAL  SEPTUM       787 

to  the  uterus.  This  may  be  true  in  the  absence  of  lacerations.  The 
anterior  and  posterior  and  even  the  lateral  walls  of  the  vagina  are 
relaxed  and  may  protrude.  While  the  perineum  is  normal  in  its  extent, 
and  may  even  be  greater  than  the  normal  dimensions  through  stretch- 
ing, the  examining  finger  readily  demonstrates  its  laxity  and  condemns 
it  as  an  efficient  supporting  body.  The  levator  fibers  are  greatly  relaxed 
and  lie  parallel  to  the  lateral  walls  of  the  vagina. 


Fig.  544 


Relaxation  of  the  pelvic  floor. 


The  thumbs  inserted  laterally  in  the  vagina  demonstrate  the  loss 
of  retaining  power. 


The  extent  of  relaxation  may  be  demonstrated  by  inspection.  With 
the  patient  in  the  dorsal  position,  she  is  directed  to  strain.  This  effort 
causes  the  outlet  to  gap  and  to  expose  the  protruding  walls  of  the 
vagina.  A  finger  against  the  cervix  will  note  the  descent  of  the  uterus 
during  the  act  of  straining.  The  perineum  is  felt  as  a  thin  partition — 
an  altogether  inadequate  support  to  the  uterus.  There  is  also  noted 
an  absence  of  the  well-developed  levator  fibers  stretching  from  one 
ramus  of  the  pubis  to  the  other,  and  in  the  place  of  this  firm  diaphragm 
there  is  a  sharp-edged,  lax  loop  of  fibers.  Such  a  condition  is  as  impera- 
tive an  indication  for  repair  as  an  incomplete  laceration  of  the  perineum. 

Operation. — For  the  restoration  of  a  relaxed  outlet  the  operation 
advised  for  incomplete  lacerations  is  most  serviceable.  The  operation 
of  Holden  for  simplicity  and  effectiveness  is  admirable.  (See  page 
769.) 


788 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


After-treatment  of  Plastic  Operations  on  the  Pelvic  Floor. — It  is 

not  necessary  to  keep  the  patient's  knees  pinioned  after  she  has  regained 
consciousness.  She  may  be  permitted  to  change  her  position  in  bed 
at  her  own  volition.  After  urinating,  the  perineum  should  be  douched 
with  an  antiseptic  solution,  preferably  lysol  or  creolin,  1  to  200,  and  a 
fresh  sterile  pad  applied.  The  bladder  should  not  be  catheterized  if 
it  can  be  avoided,  for  fear  of  creating  cystitis. 

Fig.  545 


Relaxation  of  the  pelvic  floor  and  sphincter  ani. 

The  bowels  should  be  opened  on  the  fourth  day.  The  author  usually 
administers  a  half-ounce  to  an  ounce  of  castor  oil,  followed  in  six  hours 
by  an  enema.  When  the  sphincter  has  been  repaired  he  generally  orders 
a  sweet  oil  or  glycerin  enema.  When  the  sphincter  is  not  involved  it 
is  his  custom  to  order  a  compound  enema  composed  of  1  ounce  of  salts, 
1  ounce  of  glycerin,  and  3  ounces  of  sweet  oil.  If  there  is  much  gas  in 
the  bowel,  1  dram  of  turpentine  may  be  added  to  the  enema. 

The  stitches  are  removed  on  the  tenth  to  the  fourteenth  day,  and 
the  patient  allowed  to  sit  up. 

The  author  has  recently  followed  the  suggestion  of  John  G.  Clark 
in  discarding  silkworm-gut  sutures  for  subcutaneous  chromic  catgut 
in  uniting  the  skin  margins  of  the  perineum.  This  gives  great  comfort 
to  the  patient,  and  affords  adequate  support. 


WOUNDS  OF  THE  VAGINA 


Etiology. — Lacerations  and  contusions  of  the  vaginal  walls  are  not 
rare.    They  are  usually  the  result  of  labor,  coitus,  and  external  violence. 


WOUNDS  OF  THE  VAGINA  789 

1.  Labor. — Injuries  to  the  vaginal  walls  are  the  result  of  labor,  and 
are  due  to  tearing  of  the  tissues  and  to  pressure  leading  to  contusion 
and  sloughing  of  the  tissues.  An  impacted  head  may  lead  to  pressure 
necrosis  of  the  vaginal  walls  and  the  subsequent  development  of  fistulse 
communicating  with  the  bladder  or  rectum.  The  faulty  application 
of  the  obstetric  forceps  may  lacerate  the  vaginal  walls,  and  such 
lacerations  are  known  to  extend  into  the  bladder,  rectum,  broad  liga- 
ments, and  peritoneal  cavity.  The  forcible  overstretching  of  the 
vagina  by  the  hand  in  performing  a  podalic  version  is  known  to  produce 
similar  lacerations. 

2.  Coitus. — In  the  young  and  aged  coitus  is  known  to  produce  exten- 
sive lacerations  of  the  vaginal  walls.  All  congenital  and  acquired 
constrictions  of  the  vagina  predispose  the  vaginal  walls  to  injury  in 
coitus. 

3.  External  Violence. — Foreign  bodies,  such  as  splinters  of  wood, 
have  been  know^n  to  penetrate  the  vagina.  The  author  has  seen  per- 
forations of  the  vaginal  wall  by  a  probe  in  the  hands  of  the  patient, 
and  instances  are  not  rare  in  which  the  surgeon  has  accidentally  injured 
the  vaginal  walls  with  instruments.  Foreign  bodies,  notably  pessaries, 
are  known  to  cause  pressure  necrosis  leading  to  ulceration,  cicatrization, 
and  to  perforation  into  the  bladder  and  bowel. 

Symptoms. — The  symptoms  depend  upon  the  location  and  extent 
of  the  injury.  A  small  wound  may  be  unnoticed.  When  occurring 
in  labor  the  symptoms  are  often  masked  by  associated  lesions.  The 
symptoms  common  to  injuries  to  the  vaginal  walls  are  pain,  hemorrhage, 
and  impaired  functions  of  the  neighboring  organs. 

The  pain  is  of  short  duration  and  the  bleeding  is  seldom  profuse. 
When  the  bladder  and  rectum  are  injured  their  functions  are  disturbed. 
There  may  be  incontinence  or  retention  of  urine;  urination  may  be 
painful  and  blood  may  appear  in  the  urine.  Likewise  in  injuries  to 
the  wall  of  the  rectum  there  may  be  incontinence  of  feces,  from  the 
development  of  a  rectovaginal  fistula,  and  the  bowel  movements  may 
be  painful  and  bloody. 

Results  of  Injuries  to  the  Vaginal  Walls. — As  the  results  of  injury 
to  the  vaginal  walls,  the  following  conditions  are  known  to  arise :  shock, 
sepsis,  serious  and  even  fatal  hemorrhage,  rectovaginal  fistula,  vesico- 
vaginal fistula,  ileo vaginal  fistula,  vaginal  hernia,  and  peritonitis. 

Treatment. — After  the  completion  of  labor  it  is  imperative  to  carefully 
inspect  the  vaginal  walls,  and  if  found  lacerated  the  wound  should  be 
immediately  repaired.  With  the  patient  in  the  lithotomy  position  the 
vaginal  walls  can  be  readily  inspected  by  inserting  a  vaginal  retractor. 

Hemorrhage  is  controlled  by  packing  the  vagina  with  sterile  gauze. 
When  this  does  not  suffice  to  control  the  bleeding,  the  wound  should 
be  exposed  by  a  vaginal  retractor  and  the  bleeding-points  secured  by 
suturing  the  margins  of  the  w^ound,  either  with  silkworm  gut  or  chromic 
catgut.  The  possibility  of  injury  to  the  bladder,  rectum,  and  peritoneum 
must  be  borne  in  mind  and  a  careful  inspection  made  to  determine 
not  only  the  points  of  bleeding  but  also  the  extent  of  the  wound.    If 


790  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

the  peritoneal  cavity  is  invaded,  no  vaginal  douches  should  be  given  for 
fear  of  contaminating  the  peritoneal  cavity.  When  the  peritoneal 
cavity  is  invaded,  the  wound  leading  to  the  peritoneal  cavity  should 
be  drained  with  iodoform  gauze,  and  under  no  circumstances  should  it 
be  sutured.  All  clean-cut  wounds  should  be  closed  by  interrupted 
silkworm  or  chromic  catgut  sutures.  When  the  tissues  are  badly 
contused  it  is  not  wise  to  suture  the  wound.  In  this  event  the  wound 
should  be  packed  loosely  with  iodoform  gauze  and  allowed  to  heal  by 
granulations.  The  vulva  should  be  protected  by  a  sterile  gauze  pad, 
held  in  place  by  a  T-binder.  Rest  in  bed  should  be  enjoined  for  at 
least  one  w^eek. 


ACQUIRED  STENOSIS  AND  ATRESIA  OF  THE  VAGINA 

The  lumen  of  the  vagina  may  be  partially  or  wholly  constricted 
as  the  result  of  injury. 

Etiology. — Operations. — The  vagina  may  be  constricted  by  the 
operator  in  the  performance  of  plastic  operations  upon  the  vaginal 
walls. 

Ulcerations. — Ulcers  with  subsequent  cicatrization  may  result  in 
stenosis  of  the  vagina.  These  ulcers  are  due  to  neglected  and  badly 
fitting  pessaries,  to  pressure  necrosis  from  the  fetal  head,  to  caustic 
applications  to  the  vaginal  walls,  and  to  infectious  diseases,  such  as 
syphilis,  typhoid  fever,  diphtheria,  and  scarlet  fever. 

Lacerations. — Lacerations  are  due  to  causes  enumerated  on  page  789. 

Symptoms. — If  the  atresia  is  complete  and  the  patient  is  in  the 
period  of  sexual  activity,  there  will  be  an  obstruction  to  the  menstrual 
flow,  and  interference  with  sexual  intercourse.  In  both  earl}'  and  late 
life  there  may  be  no  complaint  arising  from  the  condition. 

The  lesion  is  recognized  by  inspection  and  palpation.  It  is  seldom 
necessary  to  give  an  anesthetic  in  making  the  diagnosis. 

Treatment. — The  patient  is  anesthetized  and  placed  in  the  lithotomy 
position.  In  some  instances  it  is  possible  to  remove  the  obstruction 
by  stretching  the  vaginal  walls  with  the  fingers  and  preventing  the 
recurrence  of  adhesions  by  packing  the  vagina  with  iodoform  gauze. 
Such  packs  should  be  removed  every  other  day  and  the  vagina  douched 
with  an  antiseptic  solution  before  repacking. 

Firm  bands  of  adhesions  may  be  cut  with  scissors  and  the  raw  sur- 
faces cauterized  or  stitched  in  a  line  paralleling  the  .long  axis  of  the 
vagina.  When  the  cicatricial  tissue  is  dense  it  may  be  necessary  to 
make  multiple  parallel  incision  into  the  cicatricial  tissue  and  to  slowly 
dilate  the  stricture  with  hard-rubber  bougies,  after  which  a  glass  plug 
is  inserted  and  held  in  place  by  a  T-binder  until  the  incisions  are  healed. 
Because  of  the  liability  of  recurrence  the  patient  should  wear  this  plug 
two  or  more  hours  a  day  for  months,  and  if  necessary  for  years.  In 
far-advanced  cases  it  may  be  advisable  to  incise  the  cicatrix  at  intervals 
of  days  or  weeks  to  avoid  too  extensive  trauma. 


WOUNDS  OF  THE  CERVIX  791 


WOUNDS  OF  THE  CERVIX 


Wounds  of  the  cervix  are  of  special  import  because  of  their  alleged 
relation  to  cancer  of  the  cervix.  However,  it  has  not  been  conclusively 
proved  that  lacerations  of  the  cervix  bear  a  causal  relation  to  cancer, 
though  the  evidence  is  highly  suggestive.  While  it  is  rare  that  cancer 
develops  in  the  vaginal  portion  of  a  cervix  which  has  not  been  previously 
injured  through  labor  or  instrumental  dilatation,  it  must  be  admitted 
that  there  are  comparatively  few  women  who  reach  the  cancer  period 
of  life  whose  cervix  has  not  been  dilated  either  in  labor  or  by  instruments. 
This  being  true  we  would  naturally  find  a  small  percentage  of  cancer 
of  the  cervix  in  previously  injured  cervices. 

Etiology. — Labor. — Labor  is  by  far  the  most  frequent  cause  of  injury 
to  the  cervix.  It  may  be  stated  that  the  cervix  is  torn  to  a  greater 
or  lesser  extent  in  every  labor.  Small  tears  have  no  clinical  bearing 
and  do  not  need  operative  interference.  The  cervix  is  often  torn  in 
meddlesome  obstetrics.  Undue  hastening  of  the  first  and  second  stages 
of  labor  subject  the  cervix  to  injury.  In  this  connection  we  refer  to 
hurried  manual  dilatation  of  the  cervix,  to  the  administration  of  ergot 
in  the  second  stage,  to  roughness  in  performing  podalic  version,  to 
the  faulty  application  of  the  forceps,  to  the  effort  to  deliver  the  child 
through  a  cervix  that  is  not  completely  dilated,  and  to  the  premature 
rupture  of  the  bag  of  waters. 

Even  extensive  lacerations  of  the  cervix  may  be  unavoidable.  This 
is  true  of  precipitate  labors  and  to  a  certain  extent  when  the  cervix 
is  unyielding.  Old  primiparse  are  particularly  liable  to  extensive  tears 
because  of  the  rigidity  of  the  cervix.  Delivery  of  a  child  through  a 
cancerous  cervix  may  result  in  extensive  tears  with  alarming  hemor- 
rhage. In  retarded  labor  the  prolonged  pressure  of  the  head  may  result 
in  necrosis  and  extensive  loss  of  tissue. 

2.  Instrumental  Interference. — Hurried  forcible  dilatation  of  the  cervix 
by  instruments  of  divulsion  is  responsible  for  a  large  proportion  of 
injuries  to  the  cervix.  In  this  manner  the  cervix  may  be  torn  into 
the  broad  ligaments. 

Varieties. — We  will  here  speak  of  three  varieties  of  lacerations,  that 
is,  unilateral,  bilateral,  and  multiple  or  stellate.  The  tears  are  more 
often  found  in  the  left  side.  The  explanation  for  this  lies  in  the  pre- 
dominance of  the  left  occipito-anterior  presentation  of  the  fetal  head. 

We  will  also  mention  complete  and  incomplete  lacerations.  Incom- 
plete lacerations  usually  escape  notice,  but  may,  nevertheless,  afford 
an  atrium  for  infection.  Complete  tears  may  completely  divide  the 
vaginal  portion  of  the  cervix  into  anterior  and  posterior  lips,  and  may 
extend  to  the  vaginal  walls,  bladder,  and  broad  ligaments. 

Associated  Lesions. — A  moderate  degree  of  laceration  will  usually 
undergo  spontaneous  healing.  When  healing  fails,  the  cervix  usually 
becomes  congested  and  inflamed.  This  interferes  with  the  normal 
involution  of  the  cervix  following  labor  and  leaves  the  cervix  hard  and 


792  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

hypertrophied.  In  bilateral  lacerations  the  lips  become  everted  and 
expose  the  cervical  mucosa;  then  erosions  and  cystic  formations  in  the 
cervix  will  develop.    (See  page  416.) 

A  plug  of  scar  tissue  forms  in  the  angle  of  the  laceration.  This 
tissue  has  been  credited  with  exciting  certain  reflex  disturbances. 
Vesicovaginal  and  ureterovaginal  fistulte  are  occasional  results  of  ex- 
tensive lacerations.  Septic  infection  of  the  cervical  wound  may  extend 
to  the  uterus  and  its  appendages  or  to  the  cellular  tissue  of  the  broad 
ligament.  Finally,  it  is  asserted  that  cancer  is  prone  to  develop  at 
the  site  of  these  lacerations,  a  statement  that  is  not  fully  confirmed. 

Symptoms. — Aside  from  the  immediate  hemorrhage  which  follows 
upon  lacerations  of  the  cervix,  there  are  no  symptoms  which  can  be 
directly  attributed  to  the  laceration.  The  symptoms  commonly 
ascribed  to  the  lacerations  are  in  reality  due  to  the  complicating  lesions, 
that  is,  erosions,  subinvolution,  endometritis,  and  displacements  of 
the  uterus.  These  symptoms  are  leucorrhea,  menstrual  and  intermen- 
strual hemorrhages,  backache,  sterility,  the  habit  of  abortion,  and 
dysmenorrhea.  As  to  reflex  disturbances  emanating  from  a  lacerated 
cervix,  the  author  is  in  doubt.  When  they  exist  he  believes  they  are 
due  to  the  associated  lesions  rather  than  to  lacerations. 

Diagnosis. — Palpation, — A  laceration  can  be  readily  detected  by 
the  examining  finger.  The  cervix  is  enlarged,  club-shaped,  the  angle 
of  laceration  is  readily  felt,  and  the  everted  lips  present  to  the  finger 
the  velvety  mucous  membrane.  When  there  are  distended  cysts  they 
are  felt  as  shot  under  the  skin.  As  a  rule  there  is  some  tenderness  on 
examination. 

Inspection. — The  patient  is  placed  in  the  lithotomy  position  and 
the  cervix  exposed  by  a  bivalve  speculum. 

To  demonstrate  the  extent  of  laceration  and  to  differentiate  an 
eversion  from  an  erosion,  the  two  lips  of  the  cervix  are  grasped  with 
tenacula  and  approximated.  In  this  manner  the  everted  mucous 
membrane  of  the  cervical  canal  disappears.  Any  erosion  which  may 
exist  will  still  be  in  evidence  outside  the  reconstructed  external  os. 
If  the  cervix  is  deeply  infiltrated  there  will  be  difficulty  in  correcting 
the  eversion  by  this  means. 

An  incomplete  tear  is  recognized  by  passing  a  sound  into  the  cervical 
canal  and  noting  the  increased  caliber  of  the  cervical  canal.  The  tip 
of  the  sound  may  be  felt  through  the  intact  vaginal  mucous  mem- 
brane. 

Differential  Diagnosis. — A  lacerated  cervix  with  eversion  of  the  lips 
-is  to  be  distinguished  from  cancer  of  the  cervix  and  erosions.  (See 
respective  chapters.) 

Treatment. — ^More  than  half  of  the  lacerations  of  the  cervix  are  to 
be  regarded  as  physiological  and  demand  no  operative  interference. 
Only  when  the  lacerations  are  extensive  or  are  associated  with  compli- 
cating lesions,  such  as  erosions,  eversions,  and  infection,  should  surgery 
be  invoked. 


IMMEDIATE  REPAIR  OF  A  LACERATED  CERVIX 


'93 


IMMEDIATE  REPAIR  OF  A  LACERATED  CERVIX 

Only  in  event  of  uncontrollable  hemorrhage  from  the  circular  artery 
should  the  cervix  be  repaired  immediately  after  labor.  In  all  cases  of 
extensive  laceration  of  the  cervix,  not  accompanied  by  severe  hemor- 
rhage, the  author  prefers  to  suture  the  laceration  about  ten  days  after 
labor.  At  this  time  it  is  only  necessary  to  scrape  away  the  granulated 
tissue  with  a  knife  and  unite  the  torn  surfaces  with  interrupted  sutures 
of  No.  2  ten-day  chromic  catgut.  In  so  doing  an  anesthetic  is  required. 
The  first  suture  is  passed  near  the  apex  of  the  wound,  and  additional 
sutures  are  passed  at  intervals  of  one-half  inch.  The  sutures  should 
be  carried  through  the  thickness  of  the  cervix,  not  including  the  mucosa. 


Bilateral  laceration  of  the  cervix.  The  mar- 
gins of  the  lacerations  are  denuded  with  scissors 
and  the  plugs  of  scar  tissue  in  the  apices  are 
dissected  out. 


Transverse  sutures  of  Xo.  2  chromic  catgut 
are  passed  from  before  backward,  beginning  at  the 
apex. 


The  patient  should  remain  in  bed  about  five  days,  after  which  she 
may  be  allowed  to  attend  to  her  usual  duties.  Vaginal  antiseptic 
douches  should  be  given  daily  after  the  first  week  of  the  operation. 

Unsuspected  lacerations  icill  be  discovered  and  much  trouble  averted 
if  the  profession  would  adopt  the  custom  of  making  a  vaginal  examination 
of  all  cases  about  the  tenth  day  of  the  puerperium. 


794 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


Late  Operation. — Preliminary  Treatment. — Certain  complications, 
resident  in  the  cervix  and  in  the  uterus  and  its  appendages,  may  require 
treatment  before  resorting  to  a  repair  of  the  cervical  tear.  When  the 
cervix  and  neighboring  structures  are  congested,  hot  vaginal  douches, 
glycerin  and  ichthyol  tampons,  and  rest  should  be  enjoined  for  the 
time  required  to  relieve  the  congestion.  In  this  manner  better  results 
are  obtained  in  the  repair  of  lacerations. 

Choice  of  Operation. — One  of  two  steps  is  taken  in  the  repair  of 
lacerations:    either   the    cervical    tear   is    sutured    (trachelorrhaphy), 

or  the  cervix  is  amputated. 
The  choice  depends  upon  the 
associated  lesions.  If  the  cer- 
vix is  otherwise  healthy,  tra- 
chelorrhaphy is  the  operation 
of  choice;  but  if  the  cervix  is 
deeply  infiltrated,  if  extensive 
erosions  exist,  if  multiple  cysts 
are  incorporated  in  the  cervix, 
if  the  cervix  is  elongated, 
amputation  is  the  operation  of 
choice. 

Trachelorrhaphy.  —  Technic 
of  Operation. — A  general  anes- 
thetic is  administered  and  the 
patient  placed  in  the  lithotomy 
position. 

Step  1. — The  cervix  is  ex- 
posed by  a  weighted  vaginal 
speculum  and  two  lateral  re- 
tractors. The  anterior  lip  of 
the  cervix  is  grasped  by  a  bullet 
forceps. 

Step  2. — With  long  rat-tooth 
tissue  forceps  and  a  long  curved 
scissors,  the  edges  of  the  lacer- 
ation are  made  raw  by  excising 
a  strip  of  scar  tissue  the  length  of  the  tear  and  well  down  into  the 
angle  of  the  laceration,  taking  care  to  remove  the  plug  of  scar  tissue 
in  the  angle.  The  utmost  care  must  be  exercised  in  the  process  of 
denudation  for  fear  of  removing  the  mucous  membrane  that  is  to 
-form  the  cervical  canal.  For  this  purpose  a  strip  one-fourth  of  an 
inch  wide  is  left  in  the  middle  of  either  lip. 

Step  3. — Sutures  of  No.  2  ten-day  chromic  catgut  are  now  .passed  to 
unite  the  opposing  denuded  surfaces.  The  first  suture  is  passed  near 
the  angle.  A  short  cutting  needle  (Emmet's  preferred)  is  passed  from 
the  outer  margin  of  the  line  of  denudation  underneath  the  denuded 
surface  and  emerges  at  the  margin  of  the  strip  of  mucous  membrane. 
The  needle  is  then  carried  in  an  opposite  direction  through  the  opposite 


The  sutures  are  tied. 


AMPUTATION  OF  THE  CERVIX  795 

lip  of  the  cervix.  The  remaining  sutures  are  passed  at  intervals  of 
one-half  inch  until  the  external  os  is  reached,  when  they  are  all  tied. 

To  demonstrate  the  patency  of  the  cervical  canal  a  sound  should 
be  passed  through  the  cervix.  A  gauze  pack  is  now  placed  against 
the  cervix  and  a  sterile  vuh'ar  pad  adjusted  and  held  in  place  by  a 
T-binder. 

In  incomplete  lacerations  a  knife  is  passed  into  the  cervical  canal  and 
the  tissues  severed  in  a  way  that  will  make  the  laceration  complete. 
The  operation  is  then  performed  as  above. 

After-treatment. — The  patient  should  be  directed  to  urinate  in  a  bed- 
pan without  the  aid  of  a  catheter,  and  the  bowels  should  be  opened  at 
the  end  of  forty-eight  hours.  A  light  diet  is  given  and  the  patient  kept 
in  bed  for  one  week. 


AMPUTATION  OF  THE  CERVIX 

In  prolapsus  uteri  associated  with  elongation  of  the  cervix  it  is 
essential  to  shorten  the  cervix  by  amputation.  This  is  done  prior  to 
the  plastic  operations  upon  the  vaginal  walls  and  pelvic  floor,  the 
successive  steps  being:  (1)  amputation  of  the  cervix,  possibly  preceded 
by  curettage;  (2)  anterior  colporrhaphy;  (3)  posterior  colpoperineor- 
rhaphy. 

One  of  two  operations  may  be  chosen:  (1)  either  the  flap  amputation, 
in  which  a  wedge-shaped  portion  is  taken  from  the  anterior  and  posterior 
lips  of  the  cervix,  or  (2)  a  circular  amputation.  The  latter  is  preferred 
for  high  amputation. 

Technic  of  Operation. — 1.  Flap  Amputation  (Schroeder). — The  patient 
is  placed  in  the  lithotom}'  position  and  the  cervix  exposed  by  a  weighted 
speculum.  The  anterior  lip  of  the  cervix  is  grasped  by  tenacidum 
forceps  and  the  sound  introduced  to  measure  the  depth  of  the  uterine 
canal  to  determine  the  extent  of  the  amputation. 

With  sharp-pointed  scissors  the  cervix  is  divided  on  either  side  to 
the  point  at  whicii  the  amputation  is  desired.  This  forms  an  anterior 
and  posterior  lip. 

The  assistant  makes  traction  outward  and  upward  upon  the  anterior 
lip,  with  the  vulsellum  forceps,  while  the  operator  grasps  the  posterior 
lip  with  long  rat-tooth  tissue  forceps,  and  with  a  scalpel  makes  a  deep 
transverse  incision  across  the  mucosal  surface  of  the  posterior  lip  about 
one-half  inch  below  the  upper  limit  of  the  lateral  incision,  the  edge  of  the 
knife  being  directed  inward  and  upward.  Beginning  upon  the  vaginal 
surface  of  the  posterior  lip,  a  second  incision  is  made  to  extend  upward 
and  inward  to  meet  the  first  incision,  thereby  removing  the  posterior 
lip  and  leaving  a  wedge-shaped  incision.  The  raw  surface  is  then  closed 
b}^  interrupted  sutures  of  No.  2  ten-day  chromic  catgut. 

A  similar  wedge  is  removed  from  the  anterior  lip  and  sutured,  care 
being  taken  to  preserve  the  cervical  canal  intact.  The  amputated 
lips  are  then  brought  together  laterally  by  chromic  sutures.    An  anti- 


796 


TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 


septic  tampon  of  gauze  is  then  inserted  into  the  vagina  and  removed 
at  the  end  of  twent.y-four  hours,  after  which  formalin  vaginal  douches, 
1  to  2000,  are  given  daily.  After  seven  to  ten  days  the  patient  is 
permitted  to  leave  her  bed,  provided  other  conditions  permit. 

2.  Circular  Amputation  (Martin). — Traction  is  made  upon  the  cervix 
with  vulsella.  A  circular  incision  is  made  through  the  vaginal  mucosa 
of  the  cervix  about  2  cm.  above  the  external  os.     Two  short  lateral 


Fig.  549 


Fig.   550 


Amputation  of  the  cervix.  Vaginal  mucosa 
reflected  from  the  cervix  to  point  of  amputation. 
Cervix  bisected  into  an  anterior  and  posterior 
lip.  Modified  from  Doederlein  and  Kroenig. 
Step  1. 


Amputation  of  the  cervix.  Anterior  and 
posterior  lips  amputated,  leaving  a  double 
wedge  through  which  chromic  catgut  sutures 
are  passed.     Step  2. 


incisions  are  made,  one  on  either  side,  to  facilitate  the  reflexion  of  the 
mucosa.  The  mucous  membrane  is  then  stripped  upward,  laying 
bare  the  cervix  to  the  desired  point  of  amputation.  The  cervix  is  then 
divided  laterally,  with  a  knife,  into  an  anterior  and  posterior  portion, 
the  incisions  being  carried  to  the  point  of  amputation. 

An  oblique  resection  is  then  made  of  the  anterior  lip,  the  incision 
being  carried  from  within  outward  and  upward  in  such  manner  as  to 
leave  a  thin  flap  on  the  mucosal  side.    The  vaginal  flap  is  turned  over 


PERFORATING  WOUNDS  OF  THE   UTERUS 


797 


the  stump  and  its  edges  stitched  with  ten-day  chromic  catgut  to  the 
mucosa  of  the  cervical  canal. 

The  posterior  lip  is  likewise  resected  and  the  posterior  vaginal  flap 
stitched  to  the  mucosa  of  the  cervical  canaL 

On  either  side  of  the  cervical  canal  the  anterior  and  posterior 
flaps  are  united  by  chromicized  catgut. 


Fig.  551 


Amputation  of  the  cervix.    Sutures  tied,  taking  care  to  preserve  the  cervical  mucous  membrane  intact. 

step  3. 

The  operator  should  be  careful  to  preserve  the  patency  of  the  cervical 
canal.  Care  should  also  be  exercised  to  avoid  opening  into  the  peritoneal 
cavity  and  injuring  the  ureters. 

The  operative  procedures  above  described,  that  is,  amputation  of 
the  cervix,  anterior  colporrhaphy,  and  posterior  colpoperineorrhaphy, 
will  usually  suffice  for  the  correction  of  partial  prolapse  of  the  uterus. 


PERFORATING  WOUNDS  OF  THE  UTERUS 


A  distinction  is  made  between  a  penetrating  wound  of  the  uterus 
which  does  not  involve  the  entire  thickness  of  the  uterine  wall  and  a 


798  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

perforating  wound  which  passes  through  the  entire  wall  of  the  uterus 
and  into  the  pelvic  cavity. 

Frequency. — The  author  has  found  172  case  reports  of  perforating 
wounds  of  the  uterus,  but  is  inclined  to  believe  that  this  is  no  index 
to  the  sum  total  of  all  cases,  for  it  would  seem  that  but  a  small  proportion 
of  cases  are  on  record. 

Dr.  Paul  Heineck,  Chicago,  reports  two  deaths  and  one  recovery 
from  perforating  wounds  of  the  uterus  in  495  abortions  and  2343  labors 
at  term,  which  occurred  in  the  Cook  County  Hospital  of  Chicago  in 
the  five  years  ending  with  1907.  Heineck  has  tabulated  160  case  reports, 
which  were  all  he  could  find  in  the  literature  up  to  1907.  A  study 
of  his  tables  will  inspire  caution,  if  not  fear,  in  all  who  practise  intra- 
uterine  manipulations. 

It  is  interesting  to  note  that  some  of  the  early  workers  in  pelvic 
surgery  did  not  take  this  accident  seriously.  Tait  wTites  that  he  never 
saw  ill  results  from  perforation  of  the  uterus,  and  Lenoir  found  these 
cases  of  interest  because  of  their  frequency  and  innocuousness.  It  is 
the  prevailing  impression  that  curettage  is  an  operation  that  requires 
but  limited  skill  and  experience,  that  the  passing  of  a  sound  and  the 
removal  of  placental  tissue  by  the  fingers,  curet,  or  forceps  is  attended 
by  little  risk. 

Causes  of  Perforation. — The  uterus  has  been  perforated  by  dilators, 
sounds,  curets,  fingers,  douche-points,  tents,  and  various  articles  employed 
for  the  purpose  of  inducing  abortion.  Not  only  has  the  uterus  been 
perforated,  but  in  numerous  instances  a  loop  of  bowel  has  been  drawn 
through  the  rent  in  the  uterus,  with  fatal  results. 

Fatalities  have  followed  upon  curettements  in  which  the  uterus  had 
been  irrigated  with  bichloride,  lysol,  tincture  of  iodine,  etc.,  following 
a  perforation  wdth  the  curet  or  forceps. 

It  is  probable  that  the  uterus  is  more  often  torn  by  the  blades  of 
dilators  than  by  the  curet  or  sound.  In  Hessert's  case  the  uterus  was 
torn  by  a  dilator  and  the  mesentery  stripped  from  four  feet  of  the 
intestines.  The  author  has  found  34  case  reports  in  the  literature  in 
which  the  gut  had  been  dragged  through  the  wound  in  the  uterus  by 
the  curet. 

That  the  uterus  may  be  perforated  without  the  knowledge  of  the 
operator  has  been  abundantly  proved.  Now  and  then  one  fears  that 
he  has  perforated  the  uterus.  Someone  has  referred  to  such  cases  as 
pseudoperf orations.  The  conditions  which  may  lead  to  such  an 
impression  are  bicornuate  or  unicornuate  uterus,  a  dilated  uterine  end 
-of  the  Fallopian  tube,  through  which  the  sound  has  been  known  to 
pass  into  the  tube,  an  elongated  and  distorted  uterine  canal  from  the 
presence  of  tumor  formations  encroaching  upon  the  cavity  of  the 
uterus,  soft  tumor  and  placental  tissue  into  which  the  instrument 
sinks  to  an  unexpected  depth,  and,  finally,  temporary  paralysis  of  the 
uterus,  which  is  occasionally  developed  in  the  course  of  a  curettement. 

Predisposing  Factors. — In  order  to  justify  this  accident  in  the  hands 
of  experienced  and  cautious  operators,  we  have  to  consider  the  extreme 


PERFORATING  WOUNDS  OF  THE  UTERUS  799 

softness  and  thinness  of  the  uterine  wall  under  certain,  not  always 
recognizable,  conditions.  There  is  a  physiological  softening  of  the  uterine 
wall  during  the  menstrual  period,  throughout  pregnancy,  and  the  six  and 
eight  weeks  of  the  puerperium.  The  septic  uterus  of  gonorrheal,  puer- 
peral, or  postabortive  origin  may  be  so  soft  as  to  offer  slight  resistance 
to  the  examining  finger  or  instrument.  The  consistency  of  the  uterine 
wall  in  such  cases  has  been  likened  to  "butter,"  to  "goose  fat,"  and  to 
"wet  brown  paper."  Less  frequently  we  encounter  degenerated  uterine 
tumors,  gangrene  and  abscess  of  the  myometrium,  and  thinning  of 
the  wall  through  atrophic  changes.  Under  the  above  conditions  an 
operator  may  be  ever  so  cautious  and  yet  perforate  the  uterus.  He 
may  do  so  without  his  knowledge,  and  no  harm  ensue.  It  is  not  con- 
ceivable, however,  that  he  will  do  irreparable  damage  to  the  abdominal 
viscera,  or  that  he  will  fail  to  recognize  his  blunder  and  act  with  prompt- 
ness and  efficiency  should  the  occasion  arise. 

Occasionally  the  perforating  instrument  has  not  been  withdrawn. 
Trueb  found  a  bougie  in  a  retro-uterine  abscess,  also  a  catheter  in  the 
space  of  Retzius.  In  Ballard's  case  a  crochet  needle  perforated  the 
uterus,  and  finally  passed  through  the  abdominal  wall  without  interrupt- 
ing pregnancy.  Talmey  found  a  bougie  in  the  cul-de-sac  of  Douglas. 
Johnson  found  a  bougie  in  the  folds  of  the  omentum,  and  Fairchild  a 
hairpin  near  the  diaphragm.  Marchand  found  a  bougie  between  the 
two  layers  of  the  mesentery,  removed  two  years  later. 

Preventive  Measures. — We  ask.  How  can  this  accident  be  averted? 
The  author  would  formulate  the  following  suggestions: 

1.  A  careful  consideration  of  the  history,  wdth  special  reference  to 
an  existing  or  recent  pregnancy,  and  to  infection  of  the  uterus. 

2.  A  preliminary  bimanual  examination,  to  note  the  position,  size, 
form,  and  consistency  of  the  uterus,  and  the  possible  existence  of 
encroaching  lesions,  notably  pelvic  abscess. 

3.  The  careful  passage  of  the  sound,  when  the  bimanual  examination 
has  not  clearly  demonstrated  the  direction  of  the  long  axis  of  the 
uterus  and  the  depth  of  the  uterine  cavity. 

4.  Extreme  caution  in  dilating  and  exploring  the  cavity  of  the 
uterus. 

5.  Hegar  bougies  are  preferred  to  instruments  of  divulsion.  In 
dilating,  "make  haste  slowly."    Tents  can  be  dispensed  with. 

6.  In  removing  fetal  tissue  the  fingers  are  preferred  to  any  instrument. 

7.  Always  bear  in  mind  the  extreme  softriess  of  the  uterus  in  pregnant, 
puerperal,  and  infected  cases. 

8.  When  there  is  any  suspicion  of  a  perforation,  do  not  irrigate. 

9.  Do  not  undertake  to  curet  unless  you  are  prepared  to  do  an 
abdominal  operation. 

Treatment. — The  treatment  of  perforation  may  be  one  of  masterly 
inactivity  or  of  immediate  surgical  intervention.  A  comparatively 
minor  operative  procedure  may  lead  to  one  of  most  serious  import, 
and  require  the  exercise  of  the  highest  order  of  skill  and  experience  in 
abdominal  surgery,     We  may  fairly  say,  therefore,  that  one  should 


800  TRAUMATIC  INJURIES  OF  THE  GENITAL  ORGANS 

not  deliberately  assume  the  responsibility  of  a  currettement  unless  he 
is  prepared  to  meet  any  emergency  that  may  arise. 

When  the  operation  is  done  in  a  cleanly  manner  and  the  field  of 
operation  is  free  of  infection,  a  perforation  of  the  uterus  will  seldom 
prove  serious.  Under  such  conditions,  and  when  the  operator  is  confident 
that  he  has  done  no  injury  to  the  abdominal  viscera,  he  should  go  no 
farther  with  his  operation,  but  should  pack  the  uterus  lightly  with 
antiseptic  gauze,  place  the  patient  in  bed,  put  an  ice-bag  over  the 
hypogastrium,  and  administer  ergot. 

If  there  is  a  suspicion  of  injury  done  to  the  bowel,  of  hemorrhage 
into  the  peritoneal  cavity,  or  of  septic  material  having  been  conveyed 
to  the  peritoneum,  no  time  should  be  lost  in  opening  the  abdominal 
cavity  and  in  repairing  the  injury  done.  If  the  rent  in  the  uterus  can 
be  sutured  this  should  be  done,  but  the  softness  and  friability  of  the 
uterus  will  occasionally  prevent  a  successful  closure.  Hysterectomy  is 
then  the  only  alternative.  Under  no  circumstances  should  the  uterine 
cavity  be  irrigated  after  a  puncture.  As  a  rule  no  attempt  should  be 
made  to  suture  a  perforated  wound  in  an  infected  uterus;  the  uterus 
should  be  removed  and  drainage  established. 

Injury  to  the  bowel  has  usually  consisted  in  the  stripping  off  of  the 
mesentery.  When  this  is  done  the  bowel  is  thus  deprived  of  its  blood 
supply  and  must  be  resected.  Punctures  of  the  bowel  should  be 
sutured.  Vaginal  hysterectomy  has  been  done  in  a  number  of  instances 
of  perforation  of  the  uterus.  This  operation  is  open  to  the  objections 
that  possible  injuries  to  the  bowel  may  be  overlooked,  and  that  the 
uterus  may  be  unnecessarily  sacrificed — one  that  could  have  been 
safely  left  to  drainage  and  to  suture  of  the  wound. 

The  expectant  plan  of  treatment  has  been  pursued  in  66  reported 
cases  with  21  fatalities.  Abdominal  section  with  the  necessary  repairs 
have  been  done  in  72  reported  cases,  with  52  recoveries,  17  deaths,  and 

3  not  recorded;   vaginal  hysterectomy  15  times,  with  10  recoveries, 

4  deaths,  and  1  not  recorded.  Out  of  a  total  of  154  reported  cases  there 
have  been  108  recoveries,  42  deaths,  and  4  not  recorded  (Heineck). 


CHAPTER    XXXI 
FECAL  AND  GENITO-URINARY  FISTULA 


Fecal  Fistula 

Rectovaginal  Fistula 
Rectoperineal  Fistula 
Rectolabial  Fistula 
Enterovaginal  Fistula 

Genito-urinaby  Fistula 
Urethral  Fistula 
Vesical  Fistulse 


Vesicovaginal  Fistula 
Vesico-uterine  Fistula 
Vesicocervical  Fistula 

Ureteral  Fistulse 

Ureteral     Fistula     at    Vault 
Vagina 
Uretero  cy  stostomy 
Nephro-ureterectomy 


of 


FECAL  FISTULA 


Rectovaginal  Fistula. — Causes. — An  abnormal  communication  may 
be  formed  between  the  rectum  and  vagina  by  the  following  causes: 

1.  Cancer  invading  the  rectovaginal  septum". 

2.  Incomplete  healing  of  a  complete  tear  of  the  perineum. 

3.  Accidental  injury  in  performing  perineorrhaphy. 

4.  Tuberculous  and  syphilitic  ulcerations  of  the  vagina  and  rectum. 

5.  Rupture  of  perirectal  and  pelvic  abscesses  through  the  rectovaginal 
septum. 

6.  Ill-fitting  and  neglected  pessary. 

7.  Direct  violence. 

Symptoms. — The  condition  is  very  distressing.  The  patient  has 
no  control  over  the  gas,  and  this  alone  impels  her  to  shun  society. 
Unless  the  fistula  is  large,  solid  feces  will  not  pass  through  the  opening, 
but  a  small  fistula  permits  of  the  escape  of  liquid  feces.  The  escape 
of  the- feces  into  the  vagina  gives  rise  to  an  irritation  of  the  vaginal  walls 
and  vulva,  which  adds  greatly  to  the  patient's  discomfort. 

Diagnosis. — The  patient  complains  of  inability  to  control  the  gas 
and  bowel  movements.  She  is  annoyed  by  the  presence  of  feces  in 
the  vagina  and  by  the  irritation  of  the  vulvar  and  vaginal  surfaces. 

Inspection. — The  patient  is  placed  in  the  lithotomy  position  and  the 
anterior  wall  of  the  vagina  elevated  by  a  Simon  retractor.  Large  and 
moderate-sized  openings  are  readily  detected,  but  small  ones  may 
escape  detection  without  the  aid  of  a  probe  or  the  injection  of  colored 
fluid,  such  as  milk,  into  the  rectum.  By  the  aid  of  the  probe  the  open- 
ing may  be  located,  first  passing  the  index  finger  into  the  rectum  and 
searching  for  the  opening  with  a  small  probe  (Fig.  552). 

Prognosis. — Even  large  fistulse  are  known  to  heal  spontaneously, 
unless  due  to  cancer  and  possibly  syphilis  and  tuberculosis.  ^  In  operat- 
ing a  rectovaginal  fistula  of  whatever  size  one  must  bear  in  mind  the 
51 


802 


FECAL  AND  GENITO-U BINARY  FISTUL.^ 


uncertainty  of  getting  a  good  result.  The  stitches  are  very  liable  to 
become  infected,  and  the  gas  tension  within  the  bowel  subjects  the 
stitches  to  undue  strain. 

Treatment. — Tentative  and  Palliative. — In  cancerous  cases  no 
effort  should  be  made  to  repair  the  injury.  All  that  can  be  done  for 
such  cases  is  to  keep  the  parts  clean  and  in  every  way  to  add  to  the 
comfort  of  the  patient. 

Syphilitic  fistulce  should  not  be  operated  until  a  long  course  of 
antisyphilitic  treatment  is  completed. 


Rectovaginal  fistula.     Sound  passed  through  the  vagina  into  the  rectum  and  palpated 
through  the  rectum. 


Traumatic  fistulce  tend  to  heal  spontaneously  if  properly  handled. 
At  all  events  much  can  be  done  to  reduce  the  size  of  the  opening  before 
resorting  to  operative  procedures.  The  patient  should  be  kept  at 
rest  for  the  first  two  or  three  weeks,  when  she  may  be  allowed  to  take 
moderate  exercise. 

Vaginal  douches  of  formalin,  1  to  2000,  creolin  or  lysol,  1  to  300, 
should  be  given  three  or  four  times  daily.  Care  should  be  taken  to 
avoid  further  injury  by  the  douche-point.  The  bowels  should  be  kept 
open  by  mild  cathartics,  reinforced  by  soap  and  water  enemata.  As 
the  sinus  grows  smaller  its  margins  should  be  stimulated  by  lunar 
caustic,  to  be  applied  once  or  twice  a  week. 

Chronic  Cases. — Preparatoey  Treatment. — The  bowels  are  to 
be  thoroughly  emptied.  The  author's  preference  is  for  castor  oil, 
given  twenty-four  hours  before  the  operation,  and  followed  in  six  hours 
by  a  soap-and-water  enema,  given  in  the  knee-chest  position.  The 
diet  for  two  days  before  the  operation  should  be  liquid.  Before  pro- 
ceeding with  the   operation  the   sphincter   should   be  paralyzed   by 


FECAL  FISTULM 


803 


Fig.  553 


overstretching  and  a  gauze  tampon  placed  in  the  rectum  above  the 
fistula  to  protect  the  field  of  operation  from  the  contents  of  the  bowel. 
The  tampon  is  removed  at  the  completion  of  the  operation. 

Technic. — Here  the  flap-splitting  operation  of  Lauenstein  is  recom- 
mended. The  fistula  is  exposed  by  a  hanging  speculum  and  two 
lateral  retractors.  The  margin  of  the  fistula  is  pared  with  a  knife  or 
scissors.  This  renders  the  vaginal 
and  rectal  walls  raw,  with  the  least 
possible  loss  of  tissue.  A  vertical 
incision  one-half  inch  in  length  is 
carried  through  the  vaginal  wall  at 
a  midpoint  above  and  below  the 
fistula.  iVn  elliptical  incision  is 
next  made  through  the  vaginal  wall 
connecting  the  distal  ends  of  the 
vertical  incisions  on  either  side  and 
the  flap  of  vaginal  wall  is  removed. 
Interrupted  No.  2  chromic  catgut 
sutures  are  passed  from  side  to  side 
through  the  wall  of  the  rectum, 
not  including  the  mucosa;  these 
are  tied.  Next  the  vaginal  walls  are 
approximated  with  silkworm  gut. 
A  loose  pack  of  iodoform  gauze  is 
placed  in  the  vagina  and  the  opera- 
tion is  completed. 

After-treatment.  —  The  bowels 
should  not  be  opened  before  the 
morning  of  the  fourth  day,  or  later, 

if  the  condition  of  the  patient  will  permit.  The  author  has  kept  the 
bowels  locked  for  eight  days,  and  again  gas  pains  and  distention  have 
necessitated  their  being  opened  on  the  third  day.  A  liquid  diet  should 
be  given  so  long  as  the  bowels  are  locked.  The  gauze  pack  is  removed 
from  the  vagina  at  the  end  of  forty-eight  hours  and  daily  vaginal 
douches  given.  The  stitches  should  be  removed  on  the  tenth  day 
unless  infected,   in  which  case  they  should  be  removed  earlier. 

The  author  has  been  more  successful  in  the  closure  of  rectovaginal 
fistulse  since  adopting  the  method  of  splitting  the  rectovaginal  septum 
below  the  fistulous  opening  before  attempting  the  closure. 

With  a  grooved  director  as  a  guide  passed  through  the  fistulous 
opening  between  the  vagina  and  rectum,  the  tissues  are  severed  with 
a  knife.  In  this  manner  a  complete  division  of  the  pelvic  fioor  in  advance 
of  the  fistula  is  effected.  After  freshening  the  margins  of  the  fistula  by 
cutting  away  a  narrow  strip,  interrupted  sutures  of  No.  2  ten-day 
chromic  catgut  are  placed  in  the  rectal  wall  at  intervals  of  one-quarter 
of  an  inch  and  interrupted  sutures  of  linen  or  silk  are  placed  in  the 
vaginal  wall.  Great  care  should  be  taken  in  coapting  the  sphincter  ani 
muscles.     For  this  purpose  the  author  uses  interrupted  linen  sutures. 


Incision  in  Lauenstein's  operation  for  recto- 
vaginal fistula. 


804 


FECAL  AND  GEN  I  TO-URINARY  FISTULA 


Rectoperineal  Fistula. — A  fistula  may  connect  the  rectum  with  any 
point  on  the  surface  of  the  perineum.  The  first  step  in  the  operation 
for  repair  is  to  pass  a  grooved  director  through  the  fistula  and  sever 


Rectoperineal  fistula.     Sound  passed  through  the  vagina;  the  fistula  is  palpated  by  the  finger  inserted 

into  the  rectum. 


Fig.  555 


Rectoperineal  fistula.     Grooved  director  passed  through  the  fistula.     Fistulous  tract  is  laid  bare  by 
passing  the  knife  along  the  groove  of  the  director. 


FECAL  FISTULM  805 

the  tissues  which  include  the  sphincter  muscle  and  more  or  less  of  the 
perineal  body.  Sutures  are  then  passed  as  in  the  immediate  repair 
of  a  completely  lacerated  perineum. 

Fig.  556 


Rectolabial  fistula.    Sound  passed  through  fistula  is  palpated  by  finger  in  the  rectum. 

Fig.  557 


*-::s:5;x\, 


Enterovaginal  fistula.     Loop  of  small  bowel  communicates  with  the  vagina  through  the  posterior 

fornix  of  the  vagina. 

Rectolabial  Fistula.— The  fistulous  tract  leads  from  the  rectum 
to  a  point  in  the  labia  majora,  and  is  usually  the  result  of  a  rectal 
abscess  burrowing  into  the  labia. 


806 


FECAL  AND  GEN  I  TO-URINARY  FISTULA 


Treatment. — Either  an  elastic  ligature  or  a  grooved  director  is  passed 
through  the  fistula  and  the  intervening  structures  severed.  The  wound 
is  left  to  heal  by  granulation. 

Enterovaginal  Fistula. — A  communication  between  the  small  bowel 
and  the  vagina  is  the  result  of  deep  lacerations  in  labor  and  of  accidental 
perforation  of  the  bowel  in  vaginal  celiotomy.  In  lacerations  involving 
the  lower  uterine  segment  and  peritoneum  a  loop  of  bowel  may  become 
engaged  in  the  wound  and  the  resulting  sloughing  cause  a  fecal  fistula. 

Treatment. — The  treatment  consists  in  resection  of  the  bowel  through 
an  abdominal  incision.  Following  the  resection  of  the  bowel  a  side-to- 
side  anastomosis  should  be  made. 


GENITO-URINARY  FISTULA 

Urethral  Fistula. — It  is  unusual  for  a  fistula  of  the  urethra  to  be 
formed  from  any  cause.  As  a  result  of  labor  it  is  commonly  associated 
with  a  vesicovaginal  fistula.  These  fistulae  usually  involve  the  lower 
wall  and  communicate  with  the  vagina.  They  are,  as  a  rule,  located 
near  the  bladder,  and  when  so  located  they  may  be  the  cause  of  involun- 
tary loss  of  urine.  When,  however,  they  are  small  and  located  farther 
forward,  no  incontinence  of  urine  may  be  occasioned,  and  hence  their 
presence  does  not  require  operative  interference. 

Fig.  55S 


Urethrovaginal  fistula     A  sound  passed  into  the  urethra  is  palpated  by  the  finger  in  the  vagina, 
the  sound  passing  through  the  urethral  fistula. 


Treatment. — A  simple  fistula  is  closed-  by  denuding  its  margins  and 
shaping  the   opening  like   a  funnel,   with  the  base  to   the   vaginal 


GENITO-URINARY  FISTULA 


807 


surface.  Fine  linen  or  silk  sutures  are  passed  interruptedly,  carefully 
coapting  the  margins.  A  self-retaining  catheter  should  be  worn  four 
to  six  days. 

Vesical  Fistulse. — By  means  of  a  fistula  a  communication  is  estab- 
lished between  the  bladder  and  the  vagina,  uterus,  or  intestine.  The 
following  varieties  of  vesical  fistulse  are  known: 

1.  Vesicovaginal. 

2.  Vesico-uterine. 

3.  Vesicocervical. 

4.  Entero vesical. 

Fig.  559 


Vesicovaginal  fistula.    A  communication  is  established  between  the  base  of  the  bladder  and  the  vagina 
at  a  midpoint  in  the  anterior  wall  of  the  vagina. 


1.  Vesicovaginal  Fistula. — Vesicovaginal  fistula  is  most  often  the 
result  of  traumatism  during  labor.  Protracted  parturition,  in  which 
the  head  presses  firmly  upon  the  vesicovaginal  septum,  destroys  the 
vitality  of  the  tissues  and  leads  to  sloughing,  with  the  formation  of 
a  permanent  fistulous  communication  between  the  vagina  and  bladder. 
The  author  has,  at  the  present  writing,  a  case  under  observation  in  which 
the  vesicovaginal  fistula  was  caused  by  obstetric  forceps  during  the 
attempted  delivery.  It  is  seldom,  however,  that  fistula  are  caused 
by  direct  violence  in  the  use  of  forceps.  More  often  it  is  due  to  the 
long  delay  in  the  application  of  the  forceps. 

Carcinomatous  invasion  of  the  vesicovaginal  septum  is  second  in 
point  of  frequency.  Other  causes  are  vesical  calculi,  injuries  sustained 
in  vaginal  operations,  and  ulceration  from  the  pressure  of  an  ill-fitting 
pessary.  Forced  catheterization  during  labor  may  perforate  the  bladder. 
Finally,  pelvic  abscesses  may  perforate  both  into  the  bladder  and 
vagina,  thereby  forming  a  vesicovaginal  fistula. 


808 


FECAL  AND  GENITO-URINARY  FISTULA 


The  diagnosis  of  vesicovaginal  fistula  is  made  by  the  history  of  a 
possible  cause,  the  complaint  of  incontinence  of  urine  with  its  dis- 
agreeable consequences,  and,  finally,  by  direct  inspection. 

It  is  unusual  for  a  fistula  developing  after  labor  to  manifest  itself 
before  the  end  of  the  first  week,  though  it  is  possible  for  urine  to  escape 
through  the  vesicovaginal  septum  during  labor. 

The  symptoms  are  quite  characteristic.  Before  the  urine  escapes 
through  a  fistula  there  are  usually  symptoms  of  cystitis,  bloody  urine, 
and  rise  of  temperature.  A  foul-smelling  vaginal  discharge  indicates 
the  sloughing  of  the  vaginal  wall,  and  this  is  soon  followed  by  a  dribbling 
of  urine  into  the  vagina.  The  vagina,  vulva,  perineum,  and  inner 
aspects  of  the  thighs  soon  show  the  irritating  effect  of  the  urine  in  the 


Fig.  560 


Vesico-uterine  fistula.     A  communication  is  established  between  the  fundus  of  the  bladder  and  the 
uterus  at  about  the  level  of  the  internal  os. 


form  of  vulvovaginitis  and  local  dermatitis.  The  distress  and  incon- 
venience of  the  dribbling  lowers  the  vitality  of  the  patient,  and  she 
may  become  extremely  weak  and  emaciated.  Such  individuals  are 
almost  invariably  sterile.  Menstruation  may  be  absent,  irregular, 
or  painful,  but  may  also  be  perfectly  normal.  When  the  fistula  is 
high. up  and  small,  the  disturbance  may  be  slight  and  the  general 
health  unimpaired. 

Difficulty  in  voiding  urine  following  labor  should  always  suggest 
the  possible  development  of  a  urinary  fistula.  Under  such  circum- 
stances it  is  well  to  avoid  vigorous  manipulation  for  fear  of  creating 
or  extending  a  fistula  in  tissues  already  devitalized. 

Palpation  of  the  fistula  seldom  affords  satisfactory  information 
when  the  tissues  about  the  fistula  are  soft  and  necrotic.    This  is  par- 


GEN  I  TO-URINARY  FtSTULM 


809 


ticularly  true  of  a  small  opening.  In  long-standing  cases  the  puckered 
scar  tissue  and  an  opening  possibly  filled  with  soft  mucous  membranes 
may  often  be  recognized. 


Ftg.  561 


Vesicovaginal  fistula.     A  sound  passed  by  waj^  of  the  urethra  into'  the  fistulous  oponiflg  and  palpated 

by  the  finger  in  the  rectum. 

Fig.  562 


Vesicovaginal  fistula.     The  bladder  irrigated  with  sterile  water  colored  with  methylene  blue.     The 
blue  solution  will  be  seen  to  pass  through  the  fistulous  opening  into  the  vagina.      (After  Ashton.) 


A  sound  placed  in  the  bladder  and  the  index  finger  of  the  opposite 
hand  in  the  vagina  ma}'  be  brought  together  through  a  fistulous  opening. 


810 


FECAL  AND  GEN  I  TO-URINARY  FISTUL.E 


Inspection  will  give  positive  information  as  to  the  location  and  size  of 
the  fistula.  A  Sims  speculum  introduced  into  the  vagina  will  expose  the 
fistula  if  the  opening  is  large  enough.  Sterilized  milk  or  some  colored 
sterile  fluid  injected  into  the  bladder  may  be  seen  to  flow  through 
the  fistula.  The  cystoscope  will  expose  the  opening  from  the  vesical 
side  and  at  the  same  time  afford  information  respecting  the  condition 
of  the  bladder — whether  cystitis  exists  and  foreign  bodies  lie  within. 

Having  established  the  diagnosis  of  vesicovaginal  fistula,  it  becomes 
important  to  consider  the  nature  of  its  borders,  their  fixation,  tension, 
and  the  possible  existence  of  other  fistulse. 

Fig.  563 


Cervico-vesicovaginal  j^fistula.     A   communication  is  established  between  the  cervical  canal,  vagina 

and  bladder 


2.  Vesico-uterine  Fistula. — When  a  laceration  of  the  cervix  extends 
into  the  lower  uterine  segment  and  the  adherent  bladder,  it  is  possible 
for  healing  to  be  complete  in  the  lower  portion  of  the  wound,  leaving 
a  fistulous  opening  above  between  the  uterus  and  bladder. 

The  urine  may  be  discharged  in  part  through  the  cervix  and  in  part 
through  the  urethra,  depending  upon  the  size  of  the  fistulous  opening 
and  the  position  of  the  patient.  To  demonstrate  a  communication 
of  the  bladder  with  the  uterus,  inject  sterile  milk  or  sterile  colored 
"fluid  into  the  bladder  and  observe  through  a  speculum  that  the  fluid 
escapes  from  the  cervix.  To  demonstrate  that  it  is  not  a  uretero- 
uterine  fistula,  observe  that  the  flow  of  urine  from  the  cervix  is  not 
intermittent.  Catheterizing  the  ureters  will  demonstrate  them  to  be 
intact. 

3.  Vesicocervical  Fistula. — Likewise  in  extensive  lacerations  of  the 
cervix  involving  the  supravaginal  portion  and  the  base  of  the  bladder, 
a  fistulous  communication  between  the  cervical  canal  and  the  bladder 


GEN  I  TO-URINARY  FISTULA 


811 


may  be  formed  and  persist.    Such  fistulse  are  demonstrated  in  a  manner 
similar  to  that  indicated  in  vesico-uterine  fistula. 

4.  Enterovesica]  Fistula.— It  is  extremely  rare  that  a  fistulous  com- 
munication develops  between  the  bowel  and  bladder.  The  condition 
may  arise  through  ulceration  of  the  bowel  and  as  the  result  of  injury. 


Fig.  564 


Vesicocervical  fistula.     A  sound  within  the  cervix  and  another  sound  within  the  bladder  are  approxi- 
mated through  the  fistulous  opening  between  the  bladder  and  cervix. 


Treatment. — The  management  of  vesical  fistulee,  at  the  time  of  their 
development,  depends  largely  upon  the  causal  factors.  If  the  fistula 
is  the  result  of  direct  injury  in  the  course  of  an  operation,  such  as  may 
happen  in  the  performance  of  pelvic  operations,  repair  by  direct  suturing 
should  be  effected  at  the  earliest  moment.  But  when  the  fistula  is 
the  result  of  continued  pressure,  as  in  childbirth  or  vesical  calculi, 
or  when  due  to  ulcerative  processes,  no  attempt  should  be  made  to 
close  the  opening  until  the  tissues  are  placed  in  a  healthy  state.  This 
may  require  a  long  period  of  preparatory  treatment.  In  small  fistulous 
openings  a  spontaneous  cure  may  be  effected.  I  have  seen  a  vesico- 
vaginal fistula  the  size  of  a  five-cent  piece  close  spontaneously. 

Prepakatory  Treatment. — When  the  fistulse  are  the  result  of 
pressure  necrosis,  and  in  all  cases  in  which  the  margins  of  the  fistula 
are  in  an  unhealthy  state,  the  patient  should  be  kept  in  bed  and  fre- 
quent mild  antiseptic  vaginal  douches  should  be  given.  All  sloughing 
tissue  should  be  removed  with  scissors  or  curet,  and  all  unhealthy 
granulations  and  incrustations  of  salt  should  be  removed  by  the  swab, 
curet  or  cautery.    A  small  fistulous  opening  may  be  stimulated  to  heal 


812  FECAL  AND  GEN  I  TO-URINARY  FISTULA 

by  the  occasional  application  of  lunar  caustic  or  the  Paquelin  cautery. 
These  applications  should  not  be  made  oftener  than  one  week  apart, 
and  should  be  substituted  by  the  radical  operation  for  closure  of  the 
fistulous  opening  when  the  tissues  are  in  a  healthy  state  and  the  stimu- 
lating effects  of  the  applications  do  not  require  a  satisfactory  closure. 
In  long-standing  fistulse  it  is  not  probable  that  cauterization  will  effect 
a  cure. 

Fig.  5G5 


Repair  of  a  vesicovaginal  fistula.  A  vertical  incision  through  the  vaginal  mucosa  is  made  above 
and  below  the  opening  and  the  vaginal  wall  reflected  from  the  bladder  one-half  inch  from  the  margin 
of  the  fistula.     Step  1. 

^  Radical  Operation. — When  a  fistulous  tract  is  in  a  favorable 
condition  for  repair  it  is  not  advisable  to  persist  in  tentative  measures. 
The  most  satisfactory  course  to  pursue  is  through  surgical  measures. 
Too  long  delay  may  lead  to  embarrassments  from  cicatricial  contractures 
of  the  vagina.  When  such  contractures  exist  to  a  degree  that  renders 
access  to  the  fistula  difficult,  space  may  be  gained  by  making  deep 
lateral  incisions  on  either  side  of  the  rectum.  After  closing  the  fistula 
these  lateral  incisions  may  be  sutured  with  chromic  catgut.    When  the 


GEXI  TO-  URIXA  R  Y  FIS  TUL.^ 


813 


margins  of  the  fistula  are  fixed  and  distorted  from  the  presence  of 
scar  tissue,  it  may  be  difficult  to  approximate  the  margins  of  the  opening 
and  the  atrophic  condition  of  the  tissues  renders  healing  slow  and 
uncertain;  hence  the  advisability  of  operating  as  early  as  the  wound 
can  be  made  ready.  In  postpartum  cases  the  favorable  time  is  about 
the  sixth  to  the  tenth  week  of  the  puerperium. 


Fig.  566 


Repair  of  a  vesicovaginal  fistula.  Xo.  2  ten-day  chromic  catgut  sutures  are  passed  through  the 
bladder  wall,  not  including  the  mucosa;  these  are  tied  and  the  vaginal  wall  is  sutured  with  linen  or 
silkworm  gut.    Step  2. 

^Mien  the  margins  of  the  fistula  can  be  approximated  by  the  aid  of 
tenacula  without  undue  tension,  the  method  of  Sims,  Simon,  or  Jobert 
will  be  effective.  This  consists  in  denuding  the  margins  of  the  fistula 
with  as  little  loss  of  tissue  as  possible  and  closing  the  opening  by  sutures. 
It  will  bear  repetition  that  in  the  repair  of  all  fistulie  there  must  be 
the  least  possible  loss  of  tissue.  Xo  attempt  should  be  made  at  closure 
until  it  is  first  demonstrated  by  the  aid  of  tenacula  that  the  margins 
of  the  opening  can  be  approximated  without  undue  tension.  The 
following  steps  are  to  be  observed: 


814 


FECAL  AND  GENITO-URIXARY  FISTULA 


1.  Position  of  the  Patient. — Whatever  position  will  best  expose  the 
fistula  should  be  adopted.  Sims  recommended  the  left  lateral  position, 
Simon  the  elevation  of  the  hips,  but  the  majority  of  operators  prefer 
the  lithotomy  position. 

2.  Exposure  of  the  Field  of  Opemiion. — In  the  left  lateral  position, 
Sims'  speculum  should  be  used.  In  the  lithotomy  position  the  weighted 
speculum  is  used  to  retract  the  posterior  vaginal  wall,  and  to  further 
expose  the  fistula,  lateral  retractors  are  employed. 

Fig.  567 


Classical  operation,  sutures  inserted  transversely  instead  of  vertically.     (Kelly.) 


3.  Denuding  the  Margins  of  the  Fistula. — The  method  the  author 
usually  employs  differs  somewhat  from  that,  of  Sims  or  Simon.  He 
makes  a  median  vertical  incision  at  the  upper  and  lower  extremities 
of  the  fistula.  This  incision  is  about  one-half  inch  in  length,  and  extends 
only  through  the  vaginal  mucosa  and  not  into  the  bladder  w-all.  He 
then  proceeds  to  rim  about  the  margins  of  the  fistulous  opening,  thereby 
reflecting  the  vaginal  mucosa  from  the  bladder  around  the  entire  cir- 
cumference of  the  opening,  making  a  flap  about  one-half  inch  wide. 
The  opening  can  then  be  closed  without  any  loss  of  tissue,  and  in  this 
respect  the  method  has  the  advantage  over  all  others. 


GENITO-UKINARY  FISTVLM 


815 


FiG.  568 


L__— — — ^ ■ ■       b     elled  ed-'es  to  the  wound, 


816  FECAL  AND  GENITO-URINARY  FISTUL.E 


Fig.  569 


Follet's  operation.      1,  bladder  opening  after  introduction  of  sutures;  2,  uterine  opening; 
4,  extremities  of  vaginal  incision. 


GENITO-VRINARY  FISTULA  817 

4,.  Suture  of  the  Fistulous  Oj^ening.— Two  layers  of  sutures  are 
required.  The  first  is  of  No.  2  ten-daj^  chromicized  catgut;  these 
sutures  are  interrupted  and  pass  through  the  bladder  wall,  not  including 
the  mucosa.  The  second  layer  of  sutures  is  of  silk,  linen,  or  silkworm 
gut,  and  is  passed  interruptedly  through  the  vaginal  mucosa. 

In  passing  the  sutures  the  direction  of  least  resistance  must  be  ob- 
served so  that  when  the  wound  is  closed  the  line  of  suture  may  assume 

the  shape  of  one  of  the  following  characters :   V, — ,  '~^,  _f ,  ^  \  /  (j. 

Accurate  approximation  of  the  margins  is  insisted  upon.  This  will 
avoid  hemorrhage  into  the  bladder,  and  will  best  insure  closure. 
When  the  fistula  is  located  near  the  ureteral  openings,  care  must  be 
taken  to  avoid  passing  the  sutures  through  the  openings.  A  good 
safeguard  is  to  pass  a  ureteral  catheter  into  either  ureter  to  serve 
as  a  guide. 

After-treatment. — The  patient  should  remain  in  bed  one  week 
to  ten  days.  A  self-retaining  catheter  should  be  worn  for  about  five 
days.  Vaginal  douches  of  formalin,  1  to  4000,  or  lysol  or  creolin, 
0.05  per  cent.,  are  given  twice  daily.  The  bowels  and  diet  are  to  be 
carefully  regulated.  The  non-absorbable  stitches  are  to  be  removed 
on  the  twelfth  day. 

Of  late  years  a  variety  of  operations  have  been  devised  for  the  closure 
of  large  fistulse  which  cannot  be  closed  by  direct  suture  as  described 
above,  not  only  because  of  their  size  but  because  of  the  presence  of 
scar  tissue.  These  operations  are  largely  based  upon  the  principle  of 
closing  the  opening  in  the  bladder,  which  is  a  flexible  structure.  This 
is  possible  when  the  bladder  is  separated  from  the  vaginal  wall. 

Mackenrodt's  Operation. — Mackenrodt  devised  an  operation 
which  is  generally  satisfactory.  The  following  are  the  steps  of  the 
operation : 

Stey  1. — The  patient  is  placed  in  Sims'  position  and  the  fistula 
exposed  by  means  of  a  Sims  retractor.  Tenaculum  forceps  are  made 
to  grasp  the  cervix  and  other  forceps  the  urethral  prominence.  Traction 
is  made  upon  these  forceps  to  put  the  intervening  tissues  on  the  stretch. 

Ste.]}  2. — A  half-inch  incision  is  made  through  the  vaginal  wall 
immediately  above  and  below  the  fistulous  opening. 

Stej)  3. — The  vaginal  wall  is  separated  from  the  bladder  wall  on 
all  sides  of  the  fistula.  This  dissection  should  be  sufficiently  wide  to 
permit  of  easy  coaptation  of  the  margins  of  the  fistula  in  the  bladder. 

Step  4. — The  margins  of  the  fistula  are  denuded  and  then  sutured  with 
fine  linen.     Two  or  three  rows  of  interrupted  sutures  may  be  inserted. 

Step  5. — The  free  margins  of  the  vaginal  incision  are  freshened 
and  coapted  with  silkworm-gut  sutures  as  far  as  possible.  Before 
closing  the  vaginal  opening,  the  uterus  is  brought  forward  between 
the  bladder  and  vaginal  walls.  Sutures  are  passed  through  the  vaginal 
walls  and  uterus.  This  serves  the  double  purpose  of  closing  the  vaginal 
opening  and  holding  the  uterus  in  anteflexion.  When  the  vaginal 
walls  cannot  be  coapted  the  uterus  will  serve  to  fill  up  the  gap. 
52 


818 


FECAL  AND  GENITO-URINARY  FISTVLM 


Fig.  570 


Maokenrodt's  operation.     The  bladder  (1)  is  dissected  from  the  uterus  (2)  and  the  vaginal  walls 
dissected  (3-3')  until  its  edges  meet  without  tension.     (After  Kelly.) 


GENITO-URINARY  FISTULA 


819 


Fig.  571 


Mackenrodt's  operation.  The  bladder  is  closed  more  or  less  transversely,  drawing  the  part  (1) 
which  has  been  separated  from  the  uterus  forward,  thus  making  a  U-shaped  line  of  sutures.  The 
latter  should  be  catgut  and  passed  through  the  edges  of  the  bladder  without  penetrating  its  mucous 
membrane.  The  vaginal  wall  (3-3')  is  then  closed  with  silkworm  gut  passed  from  side  to  side  with- 
out entering  any  part  of  the  bladder  wall.  The  catgut  stitches  in  the  bladder  are  completely  buried. 
In  a  large  fistula  Kelly  modified  this  operation  by  leaving  the  vaginal  walls  to  close  bv  granulation. 
(After  Kelly.) 


820 


FECAL  AND  GEN  I  TO-URINARY  FISTULA 


Treatment  of  a  Vesico-uterine  Fistula.— A  small  fistula  which  establishes 
a  communication  between  the  bladder  and  uterus,  or  between  the 
bladder,  uterus,  and  vagina,  may  heal  spontaneously;  but  such  a  happy 
result  cannot  be  relied  upon.  In  operating  such  a  case,  Champney 
passed  a  probe  through  the  fistula,  bringing  it  out  of  the  cervix.  He  then 
made  a  transverse  incision  3|  cm.  long  through  the  anterior  fornix 

Fig.  572 


H.Va.W.  U. 

Ureterovaginal  fistula  from  cancer  of  the  cervix  uteri.  H.Va.W.,  posterior  vaginal  wall;  Po., 
portio  vaginalis  attacked  by  cancer;  R.,  rectum;  S.,  sound  in  the  ureter;  U.,  ureter;  Ua.,  urethra; 
Ve.,  bladder;  V.Va.W.,  anterior  vaginal  wall.     (Tandler  and  Halban.) 

of  the  vagina.  The  bladder  was  stripped  from  the  cervix  by  means  of 
scissors  and  fingers  to  a  point  well  above  the  fistula.  In  this  manner 
the  opening  into  the  cervix  and  another  into  the  bladder  were  freely 
exposed  to  view. 

The  opening  into  the  bladder  was  closed  with  several  fine  silver-wire 
sutures  passed  from  side  to  side.     The  opening  into  the  cervix  was 


GENITO-URINARY  FISTULA  821 

closed  in  a  similar  manner.  The  vaginal  wall  was  then  sutured  to 
the  cervix,  using  silkworm  gut.  A  self-retaining  catheter  was  left  in 
the  bladder. 

Ureteral  Fistulse. — An  abnormal  opening  into  the  ureter  may  establish 
a  communication  between  the  ureter  and  the  abdominal  wall,  vagina, 
bowel,  or  peritoneal  cavity,  and  so  direct  all  or  a  part  of  the  urine 
from  its  natural  course. 

Congenital  fistulse  are  of  rare  occurrence.  The  great  majority 
are  the  result  of  direct  injury  or  of  ulceration,  notably  from  ureteral 
calculi. 

Etiology. — In  earlier  times  it  was  not  uncommon  to  observe  ureteral 
fistulse  leading  into  the  vagina  or  uterus  as  the  results  of  lacerated 
wounds  produced  in  labor.  Such  instances  are  now  of  less  frequent 
occurrence. 

Of  all  causes  for  the  development  of  ureteral  fistulse  at  the  present 
day,  vaginal  hysterectomy  for  cancer  of  the  cervix  stands  first. 

There  is  less  danger  of  injuring  the  ureters  in  performing  abdominal 
hysterectomy,  though  this  operation  is  by  no  means  unattended  by 
this  danger. 

Operative  Treatment. — Various  methods  are  proposed  for  the  closure 
of  these  openings,  and  no  one  is  suitable  for  all  cases.  The  following 
methods  have  been  suggested: 

1.  Dissecting  out  the  end  of  the  ureter,  splitting  it  longitudinally 
for  the  purpose  of  preventing  contraction  of  the  orifice,  and  transplanting 
the  end  into  the  base  of  the  bladder. 

2.  Making  a  large  vesicovaginal  fistula  near  the  ureteral  fistula  and 
closing  the  upper  segment  of  the  vagina  so  that  the  urine  is  directed 
through  the  opening  into  the  bladder. 

3.  Making  a  large  vesicovaginal  fistula  near  the  ureteral  opening 
and  denuding  the  vaginal  wall  between  these  openings  and  stitching 
a  fold  of  vaginal  wall  over  the  interspace  to  form  a  channel  through 
which  the  urine  is  directed  from  the  ureter  to  the  bladder. 

4.  Direct  suture  of  a  lateral  opening  into  the  ureter  after  denuding 
its  margins. 

5.  Opening  the  abdomen,  freeing  the  severed  ureter,  and  trans- 
planting it  into  the  fundus  of  the  bladder. 

6.  Removal  of  the  kidney. 

Ureteral  Fistula  at  the  Vault  of  the  Vagina.— When  the  urine  escapes 
from  the  ureter  directly  into  the  vagina  a  simple  plastic  operation 
per  vaginam  will  usually  effect  a  cure.  The  first  step  is  to  form  an 
artificial  vesicovaginal  fistula  as  near  as  possible  to  the  ureteral  fistula, 
which  lies  in  the  vault  of  the  vagina.  Having  done  this  the  mucosa 
is  then  dissected  about  both  fistulse,  forming  a  circular  area  of  denu- 
dation within  which  are  both  the  vesicovaginal  and  ureterovaginal 
fistulse.  Accurate  approximation  of  the  sides  of  the  denuded  area  is 
then  accomplished  by  passing  interrupted  chromic  or  silkworm-gut 
sutures. 

In  order  that  this  operation  be  successful,  there  must  be  a  suffi- 


822 


FECAL  AND  GENITO-URINARY  FISTULA 


cient  amount  of  loose  vaginal  tissue  to  allow  the  approximation  of 
the  margins  of  the  area  of  denudation  without  undue  tension, 

Ureterocystostomy. — The  transplanting  of  the  divided  proximal  end 
of  the  ureter  into  the  bladder  is  done  only  in  the  presence  of  a  healthy 
ureter  and  kidney  and  when  it  is  impossible  to  bring  the  divided  ends 
of  the  ureter  together  by  direct  suture. 

The  ureter  is  to  be  transplanted  into  the  bladder  at  a  point  which 
will  provide  for  sufficient  laxity  of  the  tissues;  too  great  tension  will 
result  in  the  giving  way  of  the  sutures. 

A  median  abdominal  incision  is  made  above  the  pubis.  The  divided 
end  of  the  ureter  is  found  and  enlarged  by  an  incision  about  2  cm,  in 
length  to  prevent  subsequent  closure  of  the  end. 


Fig.  573 


Fig.  574 


Fig.  575 


Transplantation  of  the  ureters  into  the  fundus  of  the  bladder. 


An  opening  is  then  made  through  the  bladder  wall  large  enough 
to  admit  the  end  of  the  ureter.  Long  forceps  are  next  passed  through 
the  urethra  and  bladder  and  out  through  the  opening  into  the  bladder. 
With  these  forceps  the  end  of  the  ureter  is  grasped  and  drawn  into  the 
bladder.  Interrupted  sutures  of  linen  are  then  passed  through  the 
bladder  and  ureteral  walls,  but  not  penetrating  them.  Four  to  six 
such  sutures  are  required. 

When  the  ureter  is  severed  in  the  course  of  an  abdominal  operation 
and  the  divided  ends  cannot  be  brought  together  by  sutures,  the  next 
consideration  is  uterocystostomy.  Failing  in  this  the  choice  lies  between 
ureterostomy  and  nephrectomy.  If  the  condition  of  the  patient  is 
such  as  to  render  immediate  nephrectomy  hazardous,  the  divided  end 
of  the  ureter  should  be  brought  through  an  opening  in  the  abdominal 
wall  (ureterostomy)  and  left  there  until  such  time  as  the  condition  of 
the  patient  will  permit  of  nephrectomy. 

Uretero-ureterostomy  is  the  splicing  of  the  divided  ureter  and  is 
the  operation  of  choice  when  the  kidney,  ureter,  and  periureteral 
tissues  are  healthy  and  when  the  divided  ends  can  be  approximated 
without  undue  tension. 


GE XI TO-URINARY  FISTULA  823 

Nephro-ureterectomy. — As  a  last  resort  the  kidney  and  ureter  must 
be  sacrificed.  This  should  not  be  done  unless  their  integrity  is  destroyed 
and  unless  the  other  kidney  is  sufficiently  sound  to  permit  the  patient 
to  live  in  comparative  health.  If  the  condition  of  the  patient  is  such 
as  to  render  an  extensive  operation  extrahazardous,  the  kidney  may 
be  removed  alone  and  the  ureter  at  a  later  date.  It  is  best,  however, 
to  remove  them  together  when  possible,  provided  too  great  risk  is 
not  entailed. 


CHAPTER  XXXII 


DISEASES  OF  THE  URINARY  SYSTEM 


Diseases     of     the     Urethra    and 
Bl.adder 
Anatomy  and  Physiology 
Methods  of  Examination 
Percussion 
Palpation 

Catheter  and  Sound 
Inspection 
Urethroscopy 
Cystoscopy 
Malformations    and    Diseases    of 
the  Urethra 
Congenital  Malformations 
Partial    or    Complete 

Absence   ' 
Atresia 
Displacement 
Epispadias 
HjTDospadias 
Acquired  Malformations 
Dilatation 
Stricture 
Dislocations 

Prolapse  of  the  Urethral 
jMucous  Membrane 
Urethritis 
Acute 
Chronic 
Newgrowths  of  Urethra 
Caruncle 
Fibroma 
Carcinoma 
Sarcoma 
Foreign  Bodies 


Diseases  of  the  Bladder 
•     Developmental  Deformities 

A^esical  Fissures 

Double  Bladder 

Loculate  Bladder 
Malpositions  and   Malformations 

Eversion 

Hernia 
Foreign  Bodies 
Cystitis 
Hj^Deremia 
New-formations 

Myoma 

Fibroma 

Papilloma 

Adenoma 

Dermoid  Cysts 

Carcinoma 

Sarcoma 
Diseases  of  the  Ureters 
Anatomy  and  Physiology 
Methods  of  Examination 

Palpation 

Inspection 

Catheterization 

Examination  of  Urine 
Congenital  Anomalies 
Inflammations  of  the  Ureter 
Obstructions  of  the  Ureter 

Ureteral  Calculus 

Stricture 


DISEASES  OF  THE  URETHRA  AND  BLADDER 


WiNCKEL,  in  his  monograph  on  Diseases  of  the  Female  Urethra  and 
Bladder,  has  pointed  out  that  much  that  is  now  known  of  the  diseases 
of  the  urethra  and  bladder  was  known  hundreds  and  thousands  of 
years  ago,  and,  having  been  forgotten,  was  rediscovered  by  late  obser- 
vers. The  Cnidian  school  possessed  a  fairly  accurate  knowledge  of 
diseases  of  the  bladder,  as  did  the  Indians  100  B.C.  yEtius  (502-575 
B.C.)  described  ulcerative  affections  of  the  bladder,  and  Paul  of  iEgina 


DISEASES  OF  THE   URETHRA  AND  BLADDER  825 

(670  A.D.)  treated  diseases  of  the  bladder  by  means  of  injections  through 
a  catheter.  In  the  nineteenth  century  Simon  devised  a  series  of  conical 
specula  with  obturators,  by  which  the  urethra  could  be  dilated  to  an 
extreme  degree,  permitting  a  digital  examination  of  the  bladder.  From 
that  time  to  the  present,  methods  of  examining  the  urinary  tract  have 
been  rapidly  introduced  and  perfected.  We  are  especially  indebted 
to  Max  Nitze,  K.  Pawlik,  M.  Sanger,  and  Howard  Kelly,  whose  con- 
tributions to  this  department  of  the  diseases  of  women  rank  with  the 
most  important  of  the  past  century. 

The  Anatomy  and  Physiology  of  the  Urethra  and  Bladder. — 
Urethra.- — The  average  length  of  the  female  urethra  is  one  to  one  and 
a  half  inches.  It  runs  from  below  upward  and  backward  in  a  straight 
or  slightly  curved  line,  and  its  anterior  extremity  lies  about  four-tenths 
of  an  inch  below  the  symphysis. 

The  wall  of  the  urethra  is  about  one-fifth  of  an  inch  thick,  and 
possesses  an  unusual  amount  of  elastic  fiber,  which  permits  a  great 
degree  of  stretching.  The  epithelium  in  the  lower  segment  of  the 
urethra  resembles  the  stratified  epithelium  of  the  vagina,  while  that 
of  the  upper  segment  is  like  that  of  the  bladder. 

Near  the  external  urethral  orifice  Skene  found  two  crypts  which 
he  regarded  as  glands.  They  are  known  as  Skene's  ducts.  Their 
orifices,  which  open  into  the  urethral  canal,  are  about  one-twentieth 
of  an  inch  in  diameter.  The  ducts  are  about  one-quarter  of  an  inch 
long  and  run  upward  along  the  wall  of  the  urethra.  A  fine  probe  can 
be  inserted  into  them  for  about  one  inch. 

Numerous  smaller  crypts  lie  along  the  course  of  the  urethra.  These 
are  lined  with  transitional  epithelium,  the  lowermost  layer  being  a 
single  row  of  cylindrical  epithelium.  Higher  up  the  epithelium  becomes 
stratified,  cylindrical,  and  near  the  mouth  of  the  ducts  is  flat  pavement 
epitheUum.  In  addition  to  these  lacunae  there  are  numerous  small 
mucous  glands  opening  into  the  canal.  Beneath  the  mucosa  is  the 
submucosa  which  is  composed  of  an  elastic  network,  and  external 
to  this  is  the  muscular  wall,  composed  of  longitudinal  and  circular 
muscle  fibers. 

The  external  orifice  of  the  urethra  is  a  vertical  oval  opening  one-fifth 
of  an  inch  long,  while  the  internal  orifice  is  a  mere  slit. 

Bladder. — The  empty  female  bladder  lies  in  the  median  line  behind 
the  pubis  and  in  front  of  the  vagina.  When  the  bladder  is  distended 
it  inclines  slightly  to  the  right  side  and  may  reach  to  the  level  of  the 
umbilicus.  The  average  capacity  is  400  c.c,  which  is  somewhat 
less  than  that  of  the  male  bladder.  The  minimum  capacity  is  20  to 
30  grams,  and  the  maximum  3320  c.c.  (Fritsch).  The  bladder  wall 
consists  of  three  layers — peritoneal,  muscular,  and  mucous. 

1.  The  peritoneum  covers  the  fundus  of  the  bladder  and  is  refiected 
to  the  anterior  surface  of  the  body  of  the  uterus  and  to  the  anterior 
abdominal  wall.  It  is  loosely  adherent  to  the  muscularis.  When  the 
bladder  is  greatly  distended,  the  peritoneum  is  so  drawn  upward  that 
a  hand's  breadth  of  the  bladder  not  covered  with  peritoneum  presents 


826 


DISEASES  OF  THE   URINARY  SYSTEM 


above  the  pubis — a  fact  to  be  remembered  in  suprapubic  operations 
on  the  bladder. 

2.  The  middle  layer  consists  of  unstriped  muscle  fibers  arranged 
in  three  subla.yers,  namely,  an  external  layer  of  longitudinal  fibers, 
a  middle  layer  of  oblique  and  transverse  fibers,  and  an  internal  layer 
of  longitudinal  fibers. 

3.  The  internal  layer — mucosa — is  composed  of  several  layers  of 
transitional  epithelium  resting  upon  a  loose  connective-tissue  base. 
Folds  or  rugae  are  found  over  the  entire  inner  surface  of  the  bladder, 
with  the  exception  of  the  trigone  and  openings.  These  are  due  to 
laxity  of  the  mucosa.  In  the  trigone  the  mucosa  closely  adheres  to 
the  submucosa,  and  therefore  no  folds  are  to  be  seen.  Small  acinous 
glands  which  secrete  mucus  are  distributed  in  the  mucous  membrane 
of  the  fundus  and  about  the  internal  sphincter. 

Fig.  576 


P.I. 


^.gg^ 

2^^ 

^^ 

'''"'!^^^l 

1 

1 

Jife 

■ 

H 

■^p 

AHjjfe; 

S'i^ 

^  'W 

H^H 

t  ' 

* 

i    * 

Pl 

m 

mm 

s 

^'^N*.^ 

'^^^wifF 

y . 

- 

Bladder  opened,  showing  relations  of  the  ureteral  openings,  urethral  opening,  and  the  interureteric 
ligament.      P .1.,  interuteric  ligament;  Fr.,  fossa  retro-ureterica.     (Leipmann.) 


The  bladder  is  rich  in  bloodvessels.  A  thick,  capillary  network 
runs  beneath  the  superficial  epithelium  of  the  mucous  membrane. 
The  vertex  is  not  so  richly  supplied  with  bloodvessels  as  the  deeper 
parts.    The  arteries  supplying  the  bladder  are  the  superior  and  inferior 


PLATE   XXXVII 

Figure  1.      Linear    Uleer   of   Bladder  Mucosa.      Magnified. 


Figure  2.      Ulcerated   Patches   in  the  Trigone.      Slightly  Magnified. 


PLATE   XXXVIII 


Figure   1.      Cystitis  originating  in  the  Trigone  and  extending  to 
Adjacent  Surfaces.      Magnified. 


Figure  2.      Normal  Bladder  Mucosa.      Slightly  niagnified. 


DISEASES  OF   THE   URETHRA  AXD  BLADDER  827 

vesical  branches  of  the  arteria  hypogastrica.  The  veins  empty  into 
the  plexua  pudenda  vesicularis. 

The  nerve  supply  comes  from  the  plexicus  hypogastricus  inferior 
of  the  sympathetic  system  and  from  the  third  and  fourth  sacral  nerves. 

The  bladder  has  three  openings:  the  internal  orifice  of  the  urethra 
and  the  two  orifices  of  the  ureters,  which  lie  one  and  one-half  inches 
above  and  to  either  side  of  the  urethral  opening.  The  ureteral  openings 
are  separated  about  one  inch  and  are  connected  by  a  prominent  fold 
of  the  mucous  membrane,  known  as  the  ligamentum  uretericum.  The 
three  openings  forming  the  angles  of  a  triangle  are  known  as  the  irigone. 
Above  the  trigone,  on  the  posterior  wall  of  the  bladder,  is  the  has  fond, 
and  all  the  bladder  lying  above  the  level  of  the  ureteral  openings  is 
known  as  the  body  or  fundus.  That  portion  called  the  sphincter  vesicae 
probably  consists  solely  of  the  folds  of  mucous  membrane  at  the  internal 
orifice  of  the  urethra. 

Physiology  of  the  Bladder. — The  ureters  and  bladder  possess  peristaltic 
movements  by  which  the  urine  is  forced  through  the  ureters  into  the 
bladder  and  from  the  bladder  past  the  sphincter  internus.  These 
systolic  and  diastolic  movements  of  the  bladder  have  an  important 
clinical  bearing  in  that  rest  cannot  be  given  to  the  inflamed  bladder 
without  artificial  drainage.  The  anterior  wall  of  the  empty  bladder 
lies  upon  the  posterior  wall.  ^Yhen  the  urine  enters  the  bladder  it  first 
gravitates  to  the  side  pockets  and  gradually  elevates  the  anterior 
wall.  Before  the  bladder  is  distended,  the  walls  are  lax  and  flat;  after 
distention  they  become  tense  and  rounded. 

Topography  of  the  Bladder. — By  the  present  perfected  methods  of 
examination  it  is  possible  to  bring  into  view  and  to  directly  treat  all 
lesions  of  any  portion  of  the  bladder;  hence  the  necessity  of  exact 
means  of  describing  the  location  and  extent  of  these  lesions.  The 
following  scheme  of  divisions  and  subdivisions  of  the  interior  of  the 
bladder  is  proposed  by  Howard  Kelly: 

1.  The  natural  landmarks  within  the  bladder. 

2.  The  relation  of  the  bladder  to  surrounding  structm-es. 

3.  An  artificial  division  into  hemispheres  and  quadrants. 

1.  The  Natural  Landmarks  in  the  Bladder. — (a)  The  internal 
orifice  of  the  urethra  marks  the  junction  of  the  urethra  and  bladder, 

(b)  The  ureteral  orifices  are  to  be  regarded  as  the  most  important 
of  the  landmarks  of  the  bladder.  The  orifices  lie  at  the  top  or  to  one 
side  of  the  so-called  ureteral  prominences,  which  are  truncate  cones 
5x3  mm. 

(c)  Ureteral  folds  is  a  name  given  by  Kelly  to  designate  rounded 
elevations  sometimes  seen  in  the  mucosa,  stretching  backward  and 
outward  from  each  ureteral  opening  toward  the  pelvic  walls  for  a 
distance  of  about  three-quarters  of  an  inch.  They  are  regarded  by 
Kelly  as  the  terminal  ends  of  the  ureters  as  they  pass  through  the 
bladder  walls. 

(f/)  The  trigone  is  a  triangular  area  at  the  base  of  the  bladder,  having 
angles  formed  by  the  internal  urethral  and  the  two  ureteral  openings; 


828 


DISEASES  OF  THE   URIXARY  SYSTEM 


the  sides  connecting  these  openings  bound  the  trigone  and  are  about 
one  inch  long  at  the  base  and  three-quarters  of  an  inch  long  at  either 
side.     Many  of  the  lesions  of  the  bladder  are  confined  to  this  area. 

(e)  The  interureteric  ligament  connects  the  ureteral  eminences  and  is 
seen  as  a  line,  sometimes  elevated  which  separates  the  smooth,  deeper 
colored  surface  of  the  trigone  from  the  paler  surface  of  the  bladder. 

(/)  Kelly  calls  attention  to  the  important  points  relating  to  the 
fixed  and  movable  portions  of  the  bladder.  As  the  bladder  is  emptied 
the  upper  and  more  movable  portions  settle  down  into  the  lower  and 
more  fixed  portions,  like  one  saucer  within  another.  He  observes  that 
the  location  of  inflammatory  lesions  is  determined  somewhat  by  the 
movable  and  fixed  areas.  Viewing  the  interior  of  the  bladder  with  a 
cystoscope,  the  respiratory  movements  define  the  movable  area  as 
contrasted  with  the  fixed  portion. 

Fig.  577 


Expression  of  pus  from  the  ducts  of  Skene's  glands.     (Kellj'.) 


The  edges  in  which  the  two  saucers  meet,  form  three  folds,  a  posterior 
and  two  lateral  folds.  The  apices  formed  by  the  meeting  of  these  folds 
are  known  as  the  right  and  left  vesical  cornua. 

2.  Relations  of  the  Bl.\dder  to  Suerouxdixg  STErcTURES. — 
The  trigone  lies  in  close  proximity  to  the  anterior  vaginal  wall.  Above 
this  the  base  of  the  bladder  is  in  direct  apposition  to  the  supravaginal 
portion  of  the  cervix.  The  upper  half  of  the  bladder  is  loosely  covered 
with  peritoneum.  The  above  relations  are  important  in  operative 
procedures  upon  the  bladder  and  surrounding  structures. 

3.  Artificial  Divisiox  of  the  Bladder  ixto  Hemispheres  axd 
QuADRAXTS. — The  distended  bladder  may  be  regarded  as  a  sphere 
divided  into  right  and  left  hemispheres.  The  intersection  of  sagittal 
and  horizontal  planes  further  divides  the  bladder  into  quadrants — the 
right  upper  and  lower  quadrants  and  the  left  upper  and  lower  quadrants. 


DISEASES  OF  THE   URETHRA  AND  BLADDER 


829 


Methods  of  Examining  the  Urethra  and  Bladder. — 1.  Percussion. — 

A  bladder  distended  with  fluid  may  be  outlined  by  percussion.  The 
area  of  dulness  may  extend  to  the  umbilicus.  The  more  distended 
the  bladder,  the  more  conical  the  shape.  A  bladder  distended  with  air 
gives  a  high-pitched  tympanitic  note. 

2.  Palpation. — Many  of  the  lesions  of  the  urethra  and  bladder  are 
detected  by  palpation. 

(a)  The  urethra  is  directly  palpated  along  the  median  line  of  the 
anterior  vaginal  wall.  In  urethritis  palpation  will  be  painful  in  pro- 
portion to  the  intensity  and  extent  of  the  inflammation;  the  urethra 
may  be  felt  as  a  firm  cord.  Fissures  and  caruncles  at  the  urethral 
orifice  are  exquisitely  sensitive  to  pressure.  By  previously  dilating 
the  urethra  with  bougies,  it  is  possible  to  insert  the  finger  through  the 
urethra  into  the  bladder  for  the  purpose  of  detecting  irregularities 
and  foreign  growths.  Such  overstretching  often  results  in  a  temporary 
incontinence. 


The  thickened  bladder  is  engaged  between  the    index  and  middle  finger  of  the  left  hand  in  the  vagina 
and  the  fingers  of  the  right  hand  over  the  abdomen. 

(&)  The  bladder  when  empty  is  seldom  recognized  in  a  bimanual 
examination.  In  cystitis  tenderness  and  pain  are  proportionate  to 
the  intensity  and  extent  of  the  lesion.  In  chronic  cystitis,  and  par- 
ticularly in  tuberculous  cystitis,  the  thickened  bladder  wall  may  be 
distinctly  palpated  through  the  vagina.  Stone  may  _  sometimes  be 
palpated  and  outlined  in  an  abdominovaginal  examination. 

Kelly  recommends  placing  the  patient  in  the  knee-chest  position 


830  DISEASES  OF  THE   URINARY  SYSTEM 

and  letting  the  air  distend  the  vagina,  when  the  fingers  of  both  hands 
can  be  brought  close  together  and  the  entire  bladder  be  distinctly 
outlined. 

While  possible  to  palpate  a  portion  of  the  interior  of  the  bladder 
through  the  dilated  urethra,  such  a  procedure  is  no  longer  to  be  recom- 
mended in  view  of  the  more  efficient  and  less  objectionable  method 
of  direct  inspection. 

3.  By  Catheter  and  Sound. — By  the  use  of  the  catheter  the  urine  is 

evacuated  from  the  bladder,  free  of  contamination  with  products  of  the 

urethra  and  vagina.     By  the  catheter  foreign  bodies,  stricture,  and 

fistulse  are  sometimes  detected  in  the  urethra  and 

Fig.  579  bladder.     The  sound  is  a  more  efficient  instrument 

for  the  detection  of  such  conditions. 

4.  Inspection. — Inspection  of  the  urethra  and 
bladder  has  been  made  possible  by  the  contri- 
butions of  Nitze,  Casper,  Pawlik,  Skene,  Simon, 
Kelly,  and  others.  In  almost  all  diseases  of  the 
urethra  and  bladder  it  is  desirable  to  make  an 
exact  diagnosis  by  direct  inspection. 

The   lesions  involving  the   urethral   orifice  can 
jil[  be  recognized    by   direct  ocular   inspection.     Pus 

seen  to  ooze  from  the  urethra  is,  with  few  excep- 
tions, recognized    as   of    gonorrheal    origin.     The 
orifices  of    Skene  can   be   directly   inspected    by 
separating  the  lips  of  the  urethra  with  the  fingers. 
Urethral  calibrator.        By  Separating  the  labia  and  introducing  a  specu- 
lum, direct  inspection  will  disclose  a  vesicovaginal 
fistula,  vesicocele,  and  tumors  of  the  base  of  the  bladder  and  urethra 
growing  into  the  vagina. 

Urethroscopy. — An  endoscope  is  introduced  the  entire  length  of  the 
urethra.  Light  is  reflected  by  a  head-mirror  into  the  urethra  as  the 
instrument  is  withdrawn.  The  mucosa  collapses  about  the  end  of  the 
urethroscope,  forming  a  flat  funnel  which  can  be  directly  inspected. 
By  virture  of  the  compression  the  mucosa  is  unnaturally  pale.  Polyps, 
newgrowths,  foreign  bodies,  ulcers,  and  inflamed  surfaces  are  thus 
brought  into  the  field  of  vision  and  are  made  accessible  to  direct 
treatment. 

Cystoscopy. — Two  methods  of  inspecting  the  interior  of  the  bladder 
will  be  described — the  Kelly-Pawlik  and  the  Nitze.  There  are  numerous 
modifications  of  these  methods,  all  worthy  of  consideration  were  there 
space  to  devote  to  them. 

The  Nitze  cystoscope  is  not  in  general  use  in  the  United  States 
in  cystoscopic  examinations  of  women,  preference  being  given  to  the 
direct  method  of  Kelly  and  Pawlik.  On  the  Continent  the  Nitze  and 
various  modifications,  such  as  Casper's  are  quite  generally  used.  Each 
has  its  merits,  and  is  deserving  of  full  consideration. 

The  following  are  the  advantages  of  the  Nitze  cystoscope  as  compared 
with  the  Kelly-Pawlik: 


DISEASES  OF   THE   URETHRA  AND  BLADDER 


8.31 


1.  A  general  anesthetic  is  seldom  required. 

2.  The  lithotomy  position  is  used  to  the  best  advantage. 

3.  The  bladder  is  more  completely  dilated  with  water  than  with  air. 


Fig.  oSO 


Fig.  581 


Nitze's  ureter  cystoscope  for  illuminating 
the  bladder  and  simultaneous  catheteriza- 
tion of  the  ureters. 


Janet-Frank's  bladder  phantom.  Intended 
for  practising  cystoscopy,  ureteral  catheteriza- 
tion, and  intravesical  operations. 


4.  The  urethra  is  not  widel\'  dilated,  hence  incontinence  of  urine 
seldom  occurs. 

5.  Xo  assistance  is  required  in  making  the  examination. 

6.  Less  skill  and  a  shorter  time  are  required  in  making  the  examina- 
tion. 


832  DISEASES  OF  THE   URINARY  SYSTEM 

Technic. — Four  conditions  are  prerequisite  to  the  use  of  the  Nitze 
cystoscope : 

1 .  Permeability  of  the  urethra,  sufHcient  to  easily  permit  the  passage 
of  the  cystoscope.    This  requires  a  diameter  of  not  less  than  10  mm. 

2.  A  capacity  sufficient  to  retain  at  least  100  c.c.  of  fluid. 

3.  Power  on  the  part  of  the  sphincter  vesicse  to  retain  the  fluid. 

4.  Transparent  fluid. 

1.  Permeability. — It  is  essential  that  the  cystoscope  should  pass 
into  the  bladder  without  meeting  unusual  resistance;  otherwise  the  pres- 
sure on  the  mucus  glands  may  smear  the  lamp  with  mucous  secretion 
and  thereby  obscure  the  field  of  vision.  "When  an  obstruction  exists 
in  the  urethra  it  must  be  removed  before  the  cystoscope  is  introduced. 
Strictures  and  foreign  growths  of  the  urethra  are  uncommon  in  women. 
Spasmodic  contractions  of  the  sphincter  vesicae  may  obstruct  the 
passage  of  the  cystoscope,  but  this  may  be  overcome  by  slow,  continuous 
pressure  and  by  an  anesthetic. 

2.  Capacity  of  the  Bladder. — The  usual  amount  of  fluid  injected 
into  the  bladder  preparatory  to  making  a  cystoscopic  examination 
is  250  c.c.  A  capacity  of  less  than  100  c.c.  precludes  the  examination, 
because  of  imperfect  distention  of  the  bladder.  If  irritability  of  the 
urethra  and  bladder  does  not  permit  the  retention  of  a  sufficient  amount 
of  fluid  with  which  to  distend  the  bladder,  it  may  be  possible  to  over- 
come the  irritability  by  the  application  of  a  2  per  cent,  solution  of 
cocaine  to  the  sphincter  vesicae.  Injection  of  the  solution  into  the 
bladder  is  not  regarded  as  a  safe  procedure.  When  this  will  not  over- 
come the  irritability,  rest  must  be  enjoined  until  it  has  subsided.  In 
the  absence  of  cystitis,  the  irritability  readily  responds  to  the  influence 
of  cocaine  applied  to  the  urethra. 

Several  fatal  cases  of  cocaine  poisoning  have  resulted  from  injection 
of  the  solution  into  the  bladder. 

If  the  indication  for  a  cystoscopic  examination  is  urgent  in  the 
presence  of  an  irritable  bladder  and  urethra,  a  general  anesthetic  may 
be  given. 

The  female  bladder  will  not  distend  so  evenly  as  will  the  male  bladder, 
because  of  the  union  of  the  posterior  wall  with  the  cervix  and  vagina, 
and  because  of  the  possible  encroachment  of  the  uterus,  adhesions, 
pelvic  tumors,  and  other  swellings  upon  the  bladder. 

3.  Integrity  of  the  Sphincter  Vesica. — If  for  any  reason  the 
bladder  will  not  retain  the  urine,  the  Nitze  cystoscope  should  be  dis- 
carded in  favor  of  the  Kelly-Pawlik. 

-  4.  Transparent  Medium. — The  injected  fluid  must  be  sterile,  non- 
irritating,  and  transparent.  A  normal  salt  solution,  sterile  water,  or, 
preferably,  a  saturated  solution  of  boric  acid  may  be  used.  Carbolic 
acid,  bichloride  solution,  and  formalin  are  too  irritating,  causing  an 
unnatural  congestion  of  the  mucosa. 

The  lithotomy  position  is  preferred,  the  patient  lying  on  a  high 
table.  The  urethral  opening  is  cleansed  as  for  the  passing  of  a  catheter. 
The  urine  is  then  withdrawn  through  a  soft-rubber  or  glass  catheter. 


DISEASES  OF   THE   URETHRA   AXD  BLADDER  833 

and  without  withdrawing  the  catheter,  the  bladder  is  irrigated  with  a 
boric  acid  or  normal  salt  solution.  A  fountain  syringe  may  be  employed, 
but  a  piston  syringe  holding  250  c.c.  is  preferred.  When  the  injected 
fluid  is  returned  clear,  about  250  c.c.  of  the  fluid  is  left  in  the  bladder, 
preparatory  to  the  introduction  of  the  cystoscope.  As  a  rule,  the  fluid 
returns  clear  after  two  or  three  injections.  ^Mien  there  exists  a  sediment 
of  mucus,  blood,  or  pus  several  injections  may  be  required,  and  there 
are  cases  in  which  it  is  impossible  to  bring  about  perfect  clarity.  In 
such  cases  the  contained  fluid  is  being  continually  contaminated  by 
blood  and  pus  from  the  kidneys  and  ureters.  "When  this  is  the  case 
a  small  amount  of  the  fluid  should  be  injected  and  the  injection  repeated 
before  all  of  the  fluid  is  returned.  By  taking  this  precaution  the  sedi- 
ment at  the  bottom  of  the  bladder  will  not  be  disturbed.  Sometimes 
the  mucus,  pus,  and  concretions  cling  so  tightly  to  the  wall  of  the 
bladder  that  it  is  impossible  to  carry  out  a  cystoscopic  examination. 
The  fluid  may  appear  cloudy  because  the  lamp  is  smeared  with  mucus 
in  its  passage  through  the  urethra.  In  such  case  the  instrument  must 
be  withdrawn  and  cleansed. 

Cystoscopic  Appearance  of  the  Normal  Bladder. — With  the  bladder 
moderately  distended  the  surface  of  the  mucous  membrane  is  smooth. 
Circumscribed  nodular  swellings  appear  late  in  life  and  are  caused  by 
the  intersection  of  muscular  bands — the  so-called  trabeculse,  which 
traverse  the  wall  in  all  directions.  Such  nodular  elevations  are  not  to 
be  mistaken  for  tuberculous  nodules.  Between  the  trabeculfe,  which 
cross  one  another  at  all  angles,  are  irregularly  shaped  depressions. 
These  are  the  forerunners  of  the  pathological  conditions  known  as 
diverticula  and  hernia. 

Fig.  5S2 


Glass  tube  with  rubber  catheter. 


The  color  of  the  mucosa  varies  within  wide  limits.  In  the  normal 
state  this  variation  in  color  is  found  not  only  in  different  bladders, 
but  in  various  portions  of  the  same  bladder.  By  reflected  artificial 
light  the  normal  color  is  -gray  or  yellowish  rose.  The  variations  in 
color  presented  at  different  points  in  the  bladder  are  accounted  for 
by  the  relative  position  of  the  prism  to  the  field  of  vision.  For  this 
reason  the  shades  of  color  change  with  the  movements  of  the  prism. 
The  nearer  the  prism  approaches  the  surface,  the  brighter  the  color. 

The  bloodvessels  appear  as  a  fine  network  of  veins  and  arteries;  the 
base  of  the  bladder  is  more  vascular  than  are  other  portions.  With 
53 


834 


DISEASES  OF  THE   URINARY  SYSTEM 


the  exception  of  the  field  near  the  sphincter  vesicae  the  veins  are  rarely 
seen  m  the  normal  bladder. 

From  a  clinical  point  of  view  the  most  important  parts  of  the  blad- 
der are  the  trigone  and  base.     Here  foreign  bodies  and  pathological 
lesions  are  most  often   observed.     The  trigone  presents  a  smooth 
glistenmg  surface,  varying  in  color  from  gra^-  to  dark  red,  and  contains 
a  close  network  of  capillaries. 


Fig.  583 


Ure  thral  dilator. 
Fig.  584 


Glass  graduate,  with  rubber  tube  and  bulb. 


As  the  cystoscope  is  slowly  introduced,  the  first  image  to  greet  the 
eye  is  that  of  the  sphincter  vesicae,  which  appears  in  the  upper  or  lower 
segment  of  the  field  of  vision,  depending  upon  the  respective  direction 
ot  the  cystoscope;  the  image  above  is  the  lower  segment  of  the  sphincter 


DISEASES  OF  THE   URETHRA   AND  BLADDER 


835 


Fig.  585 


R.  Grady  Co. 


Ureteral  searcher. 
Fig.   5SG 


Catheter  directed  to  the  ureteral  opening 
Fig.  587 


Catheter  passing  into  the  ureter. 


836 


DISEASES  OF  THE   URINARY  SYSTEM 


and  vice  versa.  Pushing  the  instrument  forward  the  image  is  slowly 
lost  to  view.  At  the  base  of  the  bladder  the  ligamentum  uretericum  is 
seen  as  a  ridge  of  more  or  less  prominence,  running  transversely  for 
a  distance  of  about  one  inch.  Turning  the  instrument  slightly  to  the 
right  or  left,  the  ureteral  prommence  is  seen  at  the  end  of  the  ureteric 
ligament.     The  prominence  varies  in  size,  form,  and  color.     This  is 


Fig.  588 


Fig.  589 


Fig.  590 


I 


Ureteral  catheter,  with  handle 
sufficiently  reduced  to  allow  the 
speculum  to  be  withdrawn  after 
catheter  is  engaged  in  ureteral 
orifice. 


Delicate  mouse-toothed 
forceps. 


Vesical  curet.     (Kelly.) 


often  true  of  the  two  prominences  in  the  same  bladder.  The  image 
increases  in  size  and  transparency  as  the  prism  is  moved  to.ward  the 
object,  decreasing  in  size  and  becoming  darker  as  the  prism  is  with- 
drawn. It  is  important  to  look  for  small  vessels  radiating  from  the 
ureteral  prominence,  for  at  the  point  from  which  the  vessels  radiate 
the  ureteral  opening  is  found.  It  is  often  possible  to  see  the  ureteral 
openings  in  the  centre  or  at  one  side  of  the  prominence. 


DISEASES  OF  THE  URETHRA  AND  BLADDER 


837 


Difficulty  in  finding  the  ureteral  opening  is  experienced  when,  as 
occasionally  happens,  the  prominence  is  wanting.  When  one  ureteral 
opening  is  found,  the  other  is  to  be  sought  for  at  a  corresponding  point 
at  the  opposite  extremity  of  the  ureteric  ligament.  Slight  variations 
in  position  are  sometimes  observed.  One  or  both  ureteral  openings 
may  be  found  close  behind  the  sphincter  vesicae,  or  they  may  lie  some 


Fig.  591 


Evacuator  used  for  withdrawing  residual  urine. 


Fig.   592 


Cystoscope. 


distance  beyond  the  boundaries  of  the  trigone.  When  it  is  seemingly 
impossible  to  discover  the  position  of  the  ureteral  openings,  it  is  well 
to  look  for  the  ripple  of  the  urine  as  it  is  discharged  into  the  bladder 
from  the  ureters.  When  the  ureteral  openings  are  hidden  from  view 
by  folds  of  mucous  membrane,  a  greater  quantity  of  fluid  may  smooth 
out  the  folds  and  present  the  ureteral  openings  to  view. 


838 


DISEASES  OF  THE   URINARY  SYSTEM 


Air-bubbles  are  usually  present.  It  is  impossible  to  avoid  introduc- 
ing them,  but  they  are  no  embarrassment  to  the  examination.  They 
are  round,  oval,  or  hour-glass  in  form,  and  move  simultaneously  with 
the  contained  fluid. 


Fig.  593 


Ureteral  catheter  with  rubber  tube. 
Fig.   594 


Dorsal  position.     Elevated  pelvis.     (Kelly.) 


Movements  of  the  bladder  are  seen,  and  are  ascribed  to  the  respiratory 
excursions  and  to  the  movements  of  neighboring  structures. 

Salt  deposits  of  a  red  or  graj'ish-white  color  are  found  on  the  surface  of 
the  bladder  under  perfectly  normal  conditions.  They  are  distinguished 
from  pus  and  tubercles  by  their  color,  their  sharp  outlines,  and  by  the 
fact  that  they  are  a  deposit  upon  and  not  an  infiltration  of  the  mucosa. 


DISEASES  OF  THE  URETHRA  AND  BLADDER 


839 


Small  cystic  elevations,  the  size  of  a  pinhead,  may  extend  over  the 
entire  surface  of  the  bladder.  They  are  particularly  noticeable  near 
the  sphincter  vesicae.  No  pathological  significance  is  to  be  attached 
to  them. 

The  Kelly-Pawlik  method,  when  efficiently  carried  out,  is  the  most 
satisfactory  of  all  methods  of  cystoscopy.  The  fundamental  principles 
of  a  cystoscopic  examination  as  given  by  Kelly  are: 

Fig.  595 


Introducing  searcher  into  left  ureteral  orifice.     (Kelly.) 


1.  The  introduction  of  a  simple  cylindrical  speculum  into  the  bladder. 

2.  The  atmospheric  distention  of  the  bladder,  induced  slowly  by 
posture. 

3.  The  illumination  and  inspection  of  the  vesical  mucosa,  either 
by  means  of  a  direct  light,  such  as  a  small  electric  lamp  attached  to 
the  examiner's  forehead  or  to  the  mouth  of  the  speculum,  or  by  means 
of  a  strong  light  reflected  by  a  head  mirror. 

The  Technic  of  the  Examinaiion. — The  field  of  operation,  the  instru- 
ments used,  and  the  hands  of  the  operator  are  to  be  sterilized  as  for 


840 


DISEASES  OF  THE   URIXARY  SYSTEM 


an  operation.     The  bladder  and  bowel  should  be  emptied  immediately 
before  the  examination. 


Fig.  596 


Boldt  table  for  cystoscopic  examination. 


On  account  of  nervousness  on  the  part  of  the  patient  or  unusual 
irritability  of  the  urethra,  ether  anesthesia  may  be  chosen,  In  the 
majority  of  cases  no  anesthetic  is  required.  Kelly  recommends  the 
application  of  a  10  per  cent,  cocaine  solution  to  the  urethra  just 
within  the  external  orifice.  The  application  is  made  on  a  pledget  of 
cotton  wound  on  a  metal  rod.  By  this  means  the  urethra  can  be  dilated 
to  the  required  degree  without  great  suffering. 


DISEASES  OF  THE  URETHRA  AND  BLADDER 


841 


TJie  Posture  of  the  Patient.— Kelly  recommends  the  elevated  dorsal 
and  the  knee-chest  positions.  While  the  elevated  dorsal  position  is  the 
most  convenient  and  least  fatiguing  to  the  patient,  it  is  not  so  efficient, 
because  the  bladder  does  not  distend  so  perfectly  as  in  the  knee-chest 
position. 

Fig.  597 


Cystoscopic  examination.     (Webster.) 


In  the  elevated  dorsal  position  the  hips  are  elevated  eight  to  twelve 
inches  from  the  table  by  firm  pillows.  The  head  and  thorax  rest  on 
the  table.  In  order  to  secure  perfect  distention  of  the  bladder,  the 
patient  may  first  assume  the  knee-chest  position  and  a  catheter  be 
introduced  into  the  bladder,  through  which  the  air  may  enter.  In 
a  minute  or  two  the  patient  may  resume  the  elevated  dorsal  position, 
taking  care  that  the  hips  are  constantly  held  at  a  higher  level  than 
the  abdomen.     Thus  the  weight  of  the  small  intestines  is  taken  from 


842 


DISEASES  OF  THE   URIXARY  SYSTEM 


the  bladder,   and  when  the  urethra  is  dilated,   the  bladder  will   be 
perfectly  distended. 

The  knee-chest  position  is  preferred  by  Kelly,  who  regards  it  applicable 
to  all  cases.  When  the  patient  can  endure  the  exertion  no  anesthetic 
need  be  given.  The  patient  kneels  close  to  the  edge  of  a  firm  table. 
The  hips  are  kept  at  the  greatest  elevation,  while  the  breast  and  side 
of  the  face  lie  flat  upon  the  table.  The  small  of  the  back  curves  inward. 
The  knees  are  separated  about  twelve  inches.  When  an  anesthetic 
is  required,  the  body  may  be  supported  by  an  apparatus  shown  in  Fig. 
596,  or  by  an  assistant  at  either  side. 

Fig.  598 


Hand  holding  cystoscope  in  act  of  introduction.     (Kelly.) 

The  elevated  lithotomy  position'  is  of  immense  adA'antage  over  the 
dorsal  and  knee-chest  positions  advocated  by  Kell3^  During  the 
past  fifteen  years  Webster^  has  employed  the  following  method: 

"The  patient  is  placed  on  a  Boldt  operating  table  in  the  lithotomy 
position,  the  ankles  being  fastened  to  upright  rods,  the  buttocks  pro- 
jecting slightly  over  the  end  of  the  table  and  resting  on  a  rubber  pad. 
A  steel  bar,  with  two  padded  supports,  is  attached  to  the  top  of  the  table 
so  as  to  support  the  shoulders.    After  the  external  genitals  and  vagina 


1  Journal  of  the  American  Medical  As.sociation,  May  17,  1902. 


DISEASES  OF  THE   URETHRA  AND  BLADDER 


843 


are  cleansed,  the  patient  is  enveloped  in  sterile  sheets,  the  urine  is  with- 
drawn from  the  bladder,  the  urethra  is  dilated  to  the  necessary  size, 
and  a  speculum  containing  its  obturator  introduced  into  the  urethra. 
By  means  of  a  crank  the  top  of  the  table  is  turned  on  a  transverse 
axis  so  that  the  lower  end  is  elevated  and  the  upper  end  depressed. 
The  patient  is  thus  made  to  rest  on  an  inclined  plane,  being  held  by 
the  shoulder  supports,  her  trunk  being  flat  against  the  table  and  not 
bent  in  any  way,  so  that  her  respiration  is  free  and  the  anesthetic  easily 


Fig.  599 


Jk. 


Knee-breast  position.     Cystoseope  introduced;  sound  shows  position  of  anal  orifice.     (Kelly.) 


administered.  The  table  top  is  usually  raised  until  its  lower  end  is 
twenty-three  inches  above  the  normal  level.  The  obturator  is  then 
removed  from  the  speculum,  allowing  air  to  enter  and  dilate  the  bladder. 
The  examination  of  the  bladder  and  ureters  is  then  carried  out,  the 
examiner  standing  on  a  stool  so  the  eyes  may  be  well  above  the  outer 
end  of  the  speculum. 

"This  posture  has  all  the  advantages  of  the  genupectoral  position 
and  none  of  its  disadvantages.    In  difficult  cases  in  Avhich  the  distention 


844  DISEASES  OF  THE   URINARY  SYSTEM 

of  the  bladder  has  not  been  throughly  satisfactory  I  have  not  been 
able  to  get  better  results  by  trying  the  genupectoral  position." 

Dilating  the  Urethral  Orifice. — -The  dilators  are  lubricated  with 
sterile  glycerin,  and  introduced  into  the  urethra  by  a  boring  motion. 
It  is  well  to  first  calibrate  the  urethral  orifice  in  order  to  select  the 
proper  size  of  dilator.  The  small  end  of  the  conical  dilator  is  crowded 
into  the  urethra  until  it  meets  with  resistance.  The  index  finger  is  so 
placed  as  to  mark  the  point  in  contact  with  the  urethral  orifice.  This 
point  indicates  the  diameter  of  the  urethra.  A  diameter  below  ten  milli- 
meters will  probably  require  dilating.  A  dilator  slightly  less  in  diameter 
than  the  calibrator  is  chosen,  and  larger  dilators  are  successively  em- 
ployed until  the  diameter  of  the  urethra  is  increased  to  the  desired 
degree.  When  the  orifice  is  unusually  resistant  and  small,  Simon 
suggests  cutting  it  posteriorly. 

Fig.  600 


Downes'  segregator. 

Introduction  of  the  Speculum. — The  size  of  the  speculum  should  vary 
from  No.  7  to  No.  12,  according  to  the  case.  When  the  urethra  is 
small  and  sensitive,  No.  7  or  No.  8  may  best  answer  the  purpose.  With 
experience  a  No.  10  will  be  satisfactory  in  the  majority  of  cases.  The 
urethral  orifice  is  cleansed  with  boric  acid,  an  assistant  holds  the  labia 
and  buttocks  apart,  while  the  operator  grasps  the  speculum,  as  shown 
in  Fig.  598,  and  gently  forces  it  through  the  urethra  into  the  bladder. 
The  obturator  is  held  in  place  by  the  thumb  until  thecystoscope  has 
entered  the  bladder,  when  it  is  withdrawn.  A  head  mirror  reflects 
the  light  from  an  electric  drop  lamp. 

The  interior  of  the  bladder  should  be  explored  systematically,  moving 
the  speculum  from  side  to  side  and  up  and  down  as  the  occasion  requires. 

The  Segregator. — ^By  this  ingenious  instrument,  first  introduced  by 
Harris  and  modified  by  Downes,  the  urine  is  separately  collected  from 
each  ureter  as  it  passes  into  the  bladder. 

Two  catheters  are  arranged  side  by  side  within  a  flattened  tube, 
each  separate  and  movable  on  its  longitudinal  axis.  When  introduced 
into  the  bladder,  the  catheters  are  rotated  outward  on  their  long  axes 
and  separated  at  the  bladder  end.  A  metallic  lever  introduced  into 
the  vagina  of  the  female  and  into  the  rectum  of  the  male  provides  a 
water-shed  in  the  bladder,  on  either  side  of  which  the  urine  is  coflected 
from  the  corresponding  kidney.  The  urine  flows  through  the  catheters 
into  bottles.  The  application  of  the  segregator  is  simple  and  has  the 
great  advantage  of  collecting  the  urine  from  either  kidney  separately 


DISEASES  OF   THE   URETHRA   AND  BLADDER 


845 


the    ureters.     However,  it  has  not  proved  of 


without  catheterizin^ 
universal  vakie. 

Malformation  and  Diseases  of  the  Female  Urethra.— I.  Congenital 
Malformations. — Congenital  malformations  of  the  urethra  are  uncom- 
mon.^ They  consist  of  partial  or  complete  absence  of  the  urethra, 
atresia,  displacements,  epispadias,  and  hypospadias. 


Fig.  601 


Kelly-Pawlik  method  of  cystoscopy.  The  hips  are  elevated,  the  bladder  is  distended  with  air, 
the  cj'stoscope  is  inserted  into  the  bladder,  and  artificial  light  is  directed  through  the  cystoscope  into 
the  bladder. 


1.  Paktl^l  or  Complete  Absence. — Partial  or  complete  absence 
of  the  urethra  may  occur  in  the  presence  or  absence  of  other  congenital 
malformations  of  the  genito-urinary  tract.  All  trace  of  the  urethra  may 
be  wanting,  in  which  case  the  bladder  and  vagina  may  form  a  single 
cavity. 

2.  Atresia. — Atresia  of  the  urethra  as  a  congenital  defect  is  almost 
invariably  associated  with  malformations  of  the  bladder,  vagina,  and 
uterus.  An  outlet  for  the  bladder  is  commonly  found  to  communicate 
with  the  vagina  or  through  the  patent  urachus  to  the  navel.  If  no  such 
communication  exists,  the  bladder,  ureters,  and  kidneys  will  be  widely 
distended.    ^Mien  the  atresia  is  complete  a  channel  must  be  made  for 


846  DISEASES  OF  THE   URINARY  SYSTEM 

the  escape  of  the  urine.     This  may  be  done  through  the  symphysis  or 
urachus. 

3.  Displacement  of  the  Urethra. — The  usual  form  of  displacement 
is  that  associated  with  a  cystocele,  in  which  the  urethra  is  carried 
downward  and  forward  with  the  bladder.  It  is  possible  for  the  entire 
urethra  to  protrude  through  the  vidvar  outlet.  The  canal  may  then 
be  so  distorted  as  to  render  the  passage  of  a  catheter  or  sound  difficult. 
The  urethra  may  also  be  displaced  upward  by  a  distended  bladder, 
a  pregnant  uterus,  or  by  subperitoneal  tumors  of  the  uterus  which 
elevate  the  bladder. 

The  treatment  consists  of  the  correction  of  the  associated  lesions. 

4.  Epispadias. — Epispadias,  including  a  defect  in  the  upper  wall 
of  the  urethra,  a  divison  of  the  clitoris,  and  a  separation  of  the  labia 
minora,  is  exceedingly  uncommon.  The  associated  defects  are  separa- 
tion of  the  symphysis  and  exstrophy  of  the  bladder. 

The  treatment  must  necessarily  be  adapted  to  the  existing  condi- 
tions. The  separated  margins  of  the  urethra  are  first  denuded  and 
then  united  with  interrupted  sutures.  Following  this,  the  remaining 
severed  structures  are  denuded  and  united  by  sutures. 

5.  Hypospadias. — Hypospadias  is  a  defect  in  the  lower  wall  of  the 
urethra,  thereby  establishing  a  communication  between  the  urethra 
and  vagina. 

II.  Acquired  Malformations. — Acquired  malformations  of  the  urethra 
are  dilatations,  strictures,  diverticula,  dislocations,  and  prolapsus. 

1.  Dilatation  of  the  Urethra. — Dilatation  of  the  urethra  may 
be  confined  to  any  portion  or  may  involve  all  of  the  urethra.  Dilatation 
of  the  entire  urethra  is  usually  the  result  of  coitus  or  masturbation 
yer  urethram;  more  rarely  from  the  presence  of  a  newgrowth  or  foreign 
bodies.  The  partial  incontinence  of  urine  following  repeated  labors 
is  undoubtedly  due  to  injury  to  the  circular  fibers  of  the  urethra.  Incon- 
tinence of  urine  is  an  almost  constant  accompaniment.  Local  dilatation 
of  the  urethra,  known  as  a  urethrocele  or  diverticulum,  affects  the 
posterior  wall  of  the  urethra  immediately  back  of  the  meatus.  But 
few  cases  are  recorded. 

Treatment. — When  the  urethra  has  been  recently  dilated  by  the 
passage  of  a  stone,  instrument,  or  finger,  or  by  childbirth,  it  is  well 
to  forego  operative  interference  for  a  time  in  the  hope  that  the  urethra 
will  resume  its  normal  caliber.  When  lacerations  exist  they  should 
be  immediately  sutured,  but  not  if  the  parts  are  contused.  Silk  or 
linen  may  be  used  as  sutures. 
^     Four  methods  are  proposed  by  Kelly  for  the  relief  of  obstinate  cases: 

(a)  A  vaginal  pessary. 

(6)  A  longitudinal  resection  of  the  vaginal  walls,  with  or  without  a 
piece  of  the  urethra. 

(c)  An  operation  to  flatten  out  and  compress  the  external  urethral 
orifice. 

(d)  Twisting  the  urethra  spirally,  so  as  to  narrow  its  caliber. 
Preference  is  given  by  Kelly  to  procedure  (6). 


DISEASES  OF   THE   URETHRA   AXD  BLADDER  847 

F.  Schatz  has  devised  a  funnel-shaped  pessary  which  is  so  con- 
structed as  to  directly  press  upon  the  urethra.  AYhen  the  vaginal 
outlet  is  relaxed,  no  good  can  come  from  the  wearing  of  such  a 
pessary. 

Frank's  method  is  as  follows:  A  small  catheter  is  placed  in  the 
urethra  as  a  guide  to  the  narrowing  of  the  uretliral  canal.  A  wedge- 
shaped  piece  is  then  excised  from  the  posterior  wall  of  the  meatus, 
including  the  vaginal  wall  as  well  as  the  urethra.  This  wedge  should 
extend  backward  to  within  1  cm.  of  the  internal  sphincter.  The  incision 
proceeds  in  an  elliptical  form  beyond  the  neck  of  the  bladder  on  the 
vaginal  wall.  Interrupted  silk  or  linen  sutures  are  used  to  close  the 
incision. 

PawHk  flattens  the  outer  end  of  the  urethra  and  bends  it  sharply. 
The  urethral  orifice  is  drawn  well  forward  and  turned  to  one  side.  He 
then  marks  the  point  on  the  side  to  which  it  may  be  dra'UTi  without 
undue  tension  and  proceeds  to  denude  a  narrow  area,  about  2  cm. 
long,  and  sutures  the  urethral  orifice  to  this  raw  surface.  A  week 
later  the  other  side  of  the  urethral  orifice  is  drawn  forward,  and  to  the 
opposite  side,  where  it  is  sutured  to  a  similarly  denuded  area.  This 
gives  a  sharp  forward  bend  to  the  urethra  and  flattens  it  posteriorly. 

Gersuny  dissects  out  the  entire  urethra  and  twists  it  upon  its 
long  axis,  and  then  holds  it  in  place  with  sirtures. 

2.  Steictuee. — Stricture  of  the  female  urethra  is  uncommon  as 
compared  with  urethral  strictures  in  men.  The  causes  of  these 
strictures  are: 

(a)  Cicatrization  in  the  anterior  vaginal  wall  following  injuries 
through  labor. 

(b)  Chronic  urethritis,  usually  of  gonorrheal  origin,  the  most  frequent 
cause  of  stricture  in  the  female  as  well  as  in  the  male. 

(c)  Tumors  of  the  urethral  wall,  which  rarely  constrict  the  urethra. 

(d)  Tumors  about  the  urethra  and  displaced  uteri  directly  constrict- 
ing the  urethra. 

(e)  Cicatrization  following  a  chancre. 

(/)  Contraction  of  the  urethra  without  an  assignable  cause. 

The  diagnosis  is  made  from  the  difficulty  and  pain  experienced 
in  urinating  and  from  the  character  of  the  flow,  which  comes  in  a  fine 
stream  or  in  drops.  Not  only  the  existence  of  a  stricture,  but  its  size, 
exact  location,  and  the  caliber  of  the  urethra  are  diagnosticated  by 
calibrating  with  bougies  and  by  direct  inspection  through  a  urethro- 
scope. 

Treatment.— The  treatment  must  necessarily  be  adapted  to  the 
form  of  the  stricture  and  to  its  cause.  The  ordinary  t^-pe  of  stricture, 
due  to  gonorrheal  infection,  shotild  be  dilated  with  bougies  or  incised. 
When  the  obstruction  is  due  to  malignant  disease,  the  catheter  must 
be  employed  to  withdraw  the  urine,  and  when  this  becomes  impossible 
a  vesicovaginal  fistula  must  be  established.  Cicatricial  tissuein  the 
anterior  wall  of  the  vagina  may  constrict  the  urethra.  This  may 
be  incised,  and  if  this  fails,  the  entire  cicatricial  area  may  be  excised 


848  DISEASES  OF  THE  URINARY  SYSTEM 

and  the  wound  in  the  urethra  carefully  closed  with  silk  or  linen  inter- 
rupted sutures. 

3.  Dislocations  of  the  Urethra. — Dislocations  of  the  urethra 
may.  occur  in  any  direction,  and  such  dislocations  may  involve  the 
entire  thickness  of  the  urethral  wall  or  merely  the  mucous  membrane. 
Displacements  of  the  urethra  are  not  common,  because  of  the  anatomical 
relations,  it  being  a  short  canal  lying  immediately  underneath  the 
symphysis  and  firmly  embedded  in  connective  tissue.  Misplacement  of 
the  whole  urethra  is  the  usual  occurrence,  and  is  almost  invariably 
secondary  to  a  displacement  of  the  bladder,  as  commonly  observed  in 
a  vesicocele.  Inspection  and  the  use  of  the  sound  demonstrate  the 
exact  position  of  the  urethra.  The  external  orifice  is  directed  forward 
and  upward  and  the  internal  orifice  backward  and  downward.  The 
urethral  canal  may  be  so  distorted  as  to  render  the  passing  of  a  catheter 
or  sound  difficult.  Great  difficulty  may  be  experienced  in  voiding  the 
urine.  The  urethra  may  be  elongated  and  elevated  by  tumors,  which 
draw  the  bladder  upward;  also  by  extreme  distention  of  the  bladder, 
and  by  the  pregnant  uterus. 

4.  Prolapse  of  the  Urethral  Mucous  Membrane. — Prolapse  of 
the  urethral  mucous  membrane  is  of  rare  occurrence,  and  is  usually 
observed  in  patients  who  have  long  suffered  from  dysuria  and  vesical 
catarrh.  Displacements  of  the  uterus  and  anterior  vaginal  wall  are 
frequent  accompaniments.  Near  the  urethral  orifice  the  mucosa  is 
loosened  and  protrudes  as  a  pale  red  or  bluish,  annular,  or  crescent- 
shaped  fold  of  mucous  membrane.  This  condition  may  occur  at  any 
age,  but  is  more  common  in  girls  of  a  generally  weakened  constitution. 

Treatment. — In  very  recent  cases  an  attempt  may  be  made  to  replace 
the  prolapsed  membrane.  A  weak  solution  of  cocaine  is  used  to 
deaden  the  sensation.  Manipulations  with  the  fingers  may  succeed 
in  replacing  the  protruding  structures,  and  a  permanent  result  may 
be  gained  if  the  patient  is  kept  in  bed  for  several  days  and  a  firm  vulvar 
pad   worn. 

When  this  method  is  not  successful,  and  in  all  long-standing  cases, 
the  protruding  mucosa  should  be  excised  with  knife  or  scissors  and 
the  free  margins  united  with  fine  chromic  catgut. 

Urethritis. — In  the  female  as  in  the  male,  gonorrhea  is  the  common 
cause  of  urethritis.  In  the  absence  of  an  established  cause  for  urethritis 
the  lesion  is  assumed  to  be  gonorrheal  in  origin.  Long  after  all  clinical 
evidences  of  urethritis  have  disappeared,  the  gonococcus  may  inhabit 
the  mucosa.  Steinschneider  examined  thirty-four  cases  of  recent 
gonorrheal  infection  and  found  the  gonococcus  in  the  urethra  in  all 
of  them. 

Sometimes  the  purulent  secretion  is  seen  to  exude  from  the  urethral 
orifice,  but,  as  a  rule,  it  is  demonstrated  by  milking  the  uretfira.  (See 
Fig,  577.)  So  characteristic  is  a  purulent  discharge  from  the  urethra, 
and  so  seldom  is  it  found  in  other  than  gonorrheal  infection,  that  it 
may  be  regarded  as  almost  conclusive  evidence  of  the  gonorrheal 
nature  of  the  lesion.    A  cover-slip  preparation  of  all  secretions  of  the 


DISEASES  OF   THE   URETHRA   AND  BLADDER  849 

urethra  should  be  made,  and  at  the  same  time  of  any  existing  secretions 
from  the  cervix.  If,  as  stated  by  Kelly,  the  gonococcus  is  found  in 
the  secretion  of  the  cervix  and  not  in  the  urethra,  complicating  urethritis 
may  be  assumed  to  be  also  due  to  gonorrhea.  Suchanek  found  in  166 
cases  both  the  vagina  and  the  urethra  affected  in  122  and  urethral 
gonorrhea  existing  singly  in  only  3  cases. 

No  effort  will  be  made  to  make  a  clinical  distinction  between  the 
h;^T)eremic  and  the  inflammatory  lesions  of  the  urethra.  They  are 
dependent  upon  the  same  underlying  causes,  and  only  differ  in  degree. 
Hence,  as  additional  causes  which  occasionally  operate  to  bring  about 
a  congested  or  inflamed  urethra,  may  be  mentioned  diseases  of  the 
bladder  and  kidneys,  which  extend  to  the  urethra  or  in  which  the  urine 
irritates  the  urethra.  The  mechanical  irritation  of  the  catheter,  and 
infections  acquired  by  the  use  of  unclean  catheters,  are  occasional 
sources.  A  urethritis  sometimes  complicates  the  infectious  and  con- 
tagious diseases.  The  wearing  of  an  ill-fitting  pessary,  masturbation, 
and  excessive  sexual  intercourse  may  result  in  urethral  congestion. 
Urethritis  is  acute  and  chronic. 

1.  Acute  Urethritis. — In  this  stage  it  is  well  to  limit  local  examina- 
tions so  far  as  possible.  Under  normal  conditions  the  mucous  mem- 
brane is  pale  red  in  color,  and  there  is  a  slight  glairy  secretion.  In  the 
acute  inflammatory  stage,  the  mucosa  about  the  urethral  orifice  appears 
red  and  swollen,  sensitive  to  pressure,  and  secretes  a  variable  amount 
of  pus.  In  acute  gonorrheal  infection  of  the  urethra  there  is  at  first 
a  prickly,  burning  pain  during  and  immediately  following  urination. 
Painful  and  frequent  urination  are  constant  symptoms.  Three  or 
four  days  later  there  appears  at  the  urethral  orifice  a  serous,  sticky, 
transparent  secretion,  which  by  the  eighth  day  becomes  greenish  and 
purulent,  and  continues  so  for  about  two  weeks,  when  it  decreases 
in  amount,  and  by  the  end  of  the  first  month  may  have  entirely  dis- 
appeared. Vivid  red  points,  which  mark  the  mouths  of  infected  glands, 
are  often  seen  about  the  meatus.  The  discharge  may  cause  an  intense 
itching  about  the  vulva.  When  it  is  desired  to  inspect  the  urethra, 
a  10  per  cent,  solution  of  cocaine  should  be  applied  to  the  orifice  by  a 
swab  before  introducing  the  urethroscope.  Slight  bleeding  wfll  be 
caused  by  the  instrument.  The  congested  mucous  membrane  will 
not  appear  so  reddened  because  of  the  pressure  of  the  instrument. 

2.  Chronic  Urethritis. — Chronic  urethritis  exists  as  a  diftuse  or  circum- 
scribed lesion  that  is  easily  recognized  through  the  urethroscope.  The 
initial  stage  may  be  an  acute  infection,  but  more  often  it  is  chronic 
from  the  beginning.  The  secretion  is  limited;  the  mucosa  is  but  slightly 
swollen,  and  is  of  a  livid,  blue  color.  There  is  little  or  no  sensitiveness 
to  pressure. 

Treatment. — It  is  generafly  conceded  that  urethritis  in  the  female  is 
of  gonorrheal  origin  in  the  vast  majority  of  cases.  It  must  be  borne 
in  mind  that  the  disease  may  never  have  existed  in  the  acute  stage, 
and  that  it  may  be  located  in  isolated  areas,  notably  in  the  ducts  of 
Skene.  ^Nlany  cases  are  overlooked  or  are  regarded  as  cystitis  for  want 
54 


850  DISEASES  OF  THE   URINARY  SYSTEM 

of  an  endoscopic  examination.  A  urethroscopic  examination  should 
be  made  for  the  purpose  of  determining  the  existence  of  the  lesion,  its 
exact  location,  and  its  character. 

Xo  active  local  treatment  should  be  instituted  while  the  inflam- 
mation is  in  the  acute  stage.  The  patient  should  rest  in  bed,  frequent 
hot  vaginal  douches  of  formalin,  1  to  3000,  should  be  given,  and  the 
external  parts  bathed  in  lead-water  and  laudanum.  Large  quantities  of 
water  and  milk  should  be  drunk,  to  flush  the  urethra  from  above.  All 
alcoholic  drinks  are  prohibited. 

AMiile  not  convinced  of  the  therapeutic  value  of  urotropin  in  these 
cases,  the  author  gives  7  grains  three  or  four  times  daily.  When  there 
is  much  pain,  belladonna  or  opium  suppositories  may  be  given  per 
rectum.  Sitz  baths  may  also  serve  to  relieve  the  distress.  So  long  as 
the  acute  stage  continues,  no  suppositories  or  solutions  should  be  intro- 
duced into  the  urethra,  for  fear  of  causing  the  infection  to  extend. 

In  the  subacute  and  chronic  stages,  topical  applications  should  be 
applied. 

Silver  nitrate,  1  to  2000;  protargol,  1  to  500;  ichthyol,  i  to  100; 
these  with  many  other  solutions  have  been  used  with  varying  degrees 
of  success.  That  no  one  remedy  has  proved  eminently  satisfactory  is 
evident  from  the  large  number  of  remedies  advised,  and  the  hope- 
lessly divergent  views  of  experts  as  to  their  proper  application.  In 
the  chronic  stage  of  gonorrheal  urethritis,  it  must  be  remembered  that 
the  lesions  are  commonly  localized  in  one  or  more  areas,  and  are  best 
treated  with  strong  astringents  and  antiseptics,  or  the  cautery,  through 
an  endoscope.  For  this  purpose  a  20  per  cent,  to  50  per  cent,  silver 
nitrate  solution  may  be  employed  to  good  advantage,  the  appli- 
cations being  made  with  an  applicator.  Care  must  be  taken  not  to 
overlook  infected  follicles,  which,  when  found,  must  be  opened  and 
cauterized. 

Jullien  advocates  ichthyol  as  a  local  application  in  gonorrheal 
urethritis.  He  swabs  the  urethral  mucosa  with  a  10  to  20  per  cent, 
solution  of  ichthyol  in  glycerin,  using  a  cotton  applicator. 

General  medication  should  be  given  a  trial.  The  balsam  of  copaiba, 
15  grains  in  capsules,  -is  in  general  use.  ^^Tien  there  is  pain  on  urination 
arhovin  is  said  to  be  of  service.  It  is  given  in  capsules,  each  containing 
4  grains,  and  administered  every  two  to  four  hours.  It  is  extolled  as 
a  sedative  to  mucous  membranes. 

"\Miile  the  urethra  is  being  so  treated,  the  infection  existing  in  the 
genital  tract  demands  attention.  See  Chapter  XXIII  on  the  Treat- 
ment of  Gonorrhea  in  Women. 

Newgrowths  of  the  Urethra, — Xewgrowths  of  the  urethra  are 
more  common  in  the  female  than  in  the  male.  The  following  forms 
have  been  described: 

1.  Caruncle. 

2.  Fibroma. 

3.  Carcinoma. 

4.  Sarcoma. 


DISEASES  OF  THE  URETHRA  AND  BLADDER  851 

1.  Canincle.— Vascular  tumors  of  the  urethra,  the  so-called  caruncles, 
are  most  frequent.  No  age  is  exempt,  but  they  are  more  common  in 
advanced  years.  They  are  located  at  the  urethral  orifice,  sometimes 
extending  into  the  urethra.  They  are  sessile  or  pedunculated,  their 
form  varying  from  flat  and  nodulated  to  pedunculated  and  crenated. 
The  growth  is  very  vascular,  bleeding  freely  to  the  touch,  and  is  sensi- 
tive to  pressure.  The  surface  is  covered  with  pavement  epithelium. 
In  the  connective-tissue  stroma  is  an  abundant  distribution  of  nerve 
filaments  and  capillary  bloodvessels;  this  supply  of  nerves  accounts 
for  the  great  sensitiveness  to  pressure  and  the  pain  in  urinating. 
Sexual  intercourse  becomes  intolerable,  and  the  suffering  racks  the 
constitution. 

The  diagnosis  can  be  made  by  direct  inspection.  When  doubt 
exists  as  to  the  character  of  the  growth,  a  microscopic  section  of  the 
excised  tumor  should  be  made. 

The  treatment  is  excision  and  closure  with  fine  catgut  suture,  or 
cauterization.  Local  applications  are  unsuccessful.  A  urethral  spec- 
ulum is  required  when  the  caruncle  is  situated  high  in  the  urethra. 

The  author's  preference  is  for  the  thermocautery,  applied  under 
general  anesthesia. 

2.  Fibroma. — But  few  cases  are  recorded. 

3.  Carcinoma. — Carcinoma  of  the  urethra  is  rarely  primary,  but  is 
not  infrequently  secondary  to  carcinoma  of  the  vagina,  cervix,  and 
vulva.  The  author  has  found  but  twenty-eight  cases  of  primary  carci- 
noma of  the  urethra  in  the  literature.  The  reported  cases  show  a  variety 
of  anatomical  forms:  the  papillomatous,  nodular,  smooth,  and  infil- 
trating, and,  finally,  the  ulcerative.  Almost  all  arose  late  in  life,  as  is 
common  with  carcinoma. 

The  patient  complains  of  burning  and  smarting  while  urinating;  later 
there  is  more  or  less  bleeding.  The  endoscope  should  be  used  in  all 
cases  when  complaint  of  such  symptoms  is  made.  When  in  doubt  as 
to  the  character  of  the  growth,  a  portion  may  be  excised  or  scraped 
from  the  suspected  area  and  submitted  to  a  microscopic  examination. 
An  interesting  case  is  reported  by  Percy.^  He  calls  attention  to  the 
great  rarity  of  the  lesion  and  the  possibility  of  confusing  cancer  with 
syphilis  of  the  urethra. 

4.  Sarcoma. — But  four  cases  of  primary  sarcoma  of  the  urethra 
have  been  described.  One  was  a  myxosarcoma,  another  a  melano- 
sarcoma. 

Foreign  Bodies  in  the  Urethra. — Foreign  bodies  in  the  urethra  are 
rarely  found.  They  are  introduced  from  without  in  masturbating  or 
in  the  passage  of  sounds  and  catheters,  or  a  vesical  stone  may  lodge  in 
the  urethra. 

The  diagnosis  is  based  upon  the  complaints  of  frequent  and  painful 
urination,  the  presence  of  pus,  blood,  and  mucus  in  alkaline  urine,  and 
the  finding  of  a  foreign  body  by  palpating  the  course  of  the  urethra 

1  American  Journal  of  Obstetrics,  April,  1903. 


852  DISEASES  OF  THE   URIXARY  SYSTEM 

through  the  vagina,  by  sounding  the  urethra,  and  by  the  use  of  the 
urethroscope. 

Calculi  in  the  urethra  are  almost  invariably  composed  of  phosphates. 

Stone  lodged  in  the  urethra  may  be  removed  by  forceps  or  a  wire 
curet.  The  forefinger  of  the  left  hand  is  passed  into  the  vagina  to 
steady  the  stone  while  it  is  being  retracted.  ^Yhen  extraction  fails 
the  stone  must  be  cut  down  upon  through  the  anterior  wall  of  the 
vagina,  and  after  its  retraction  the  opening  is  closed  with  interrupted 
sutures  of  silk,  linen,  or  chromic  catgut  and  a  self-retaining  catheter 
introduced  for  three  to  five  davs. 


DISEASES  OF  THE  BLADDER 

The  vesical  diseases  of  women  differ  materially  from  those  of  men, 
and  are  deserving  of  special  consideration.    We  will  consider: 

1.  Developmental    deformities. 

2.  Malpositions  and  malformations. 

3.  Foreign  bodies. 

4.  Inflammations. 

5.  Xew-formations. 

1.  Developmental  Deformities.  —  (a)  Vesical  Fissures. — Vesical 
fissures  (exstrophy)  are  the  most  frequent  and  important  of  the  con- 
genital deformities  of  the  bladder.  They  depend  upon  a  deficiency 
of  the  anterior  wall,  and  are  mostly  associated  with  developmental 
defects  in  the  genital  organs.  Various  grades  of  this  maldevelopment 
are  observed.  It  may  consist  of  a  simple  cleft  of  the  most  dependent 
portion  of  the  bladder  or  is  less  frequently  located  near  the  umbilicus. 
In  the  other  extreme  may  be  found  an  absence  of  the  entire  anterior 
wall  of  the  bladder.  A  corresponding  portion  of  the  abdominal  wall 
is  cleft,  and  the  gap  is  filled  with  a  swollen,  red,  mucous  membrane 
continuous  with  the  external  skin.  The  pubic  bones  are  separated  one- 
half  to  three  inches  and  are  connected  by  a  fibrous  band.  The  urethra 
is  usually  wholly  wanting  and  not  infrequently  the  clitoris  is  bifurcated. 
It  is  possible  for  the  vagina  and  uterus  to  be  divided  by  a  septum,  or 
for  two  separate  vaginee  and  a  bicornate  uterus  to  exist  in  connection 
with  the  fissured  bladder.  At  times  the  posterior  wall  of  the  bladder 
inverts  through  the  abdominal  fissure.  According  to  Voss,  a  distended 
bladder  in  the  fetus  accounts  for  these  deformities.  The  distended 
bladder  forces  the  horizontal  rami  of  the  pubes  apart,  then  ruptures 
and  establishes  a  communication  between  the  bladder  and  the 
abdominal  cleft. 

Diagnosis. — The  diagnosis  is  based  upon  direct  inspection  of  the 
protruding  bladder.  The  red  mucous  membrane  of  the  bladder  is 
sensitive  to  the  touch,  the  ureteral  openings  may  be  visible,  and  urine 
may  be  seen  dribbling  from  the  ureters.  The  lower  margin  of  the 
fissure  is  reddened  and  eroded,  and  burns  and  itches  from  irritating 
urine. 


DISEASES  OF  THE  BLADDER 


853 


As  to  the  frequency  of  occurrence,  Winckel  reports  two  observed 
cases,  and  Sickel  found  2  cases  in  12,689  newborn  children. 

Treatment. — For  the  extreme  cases  there  is  Kttle  that  is  promising 
in  the  treatment.  When  there  is  no  greater  defect  than  the  presence 
of  a  vesico-umbilical  fistula,  a  funnel-shaped  area  of  denudation  is 
made  and  the  surfaces  approximated  with  non-absorbable  sutures.  In 
all  cases  with  a  defective  urethra,  no  attempt  at  closure  of  the  fissure 
should  be  attempted  unless  it  is  first  possible  to  establish  a  vesicovaginal 
fissure.  This  is  often  impossible  because  of  an  associated  closure  of 
the  vagina.  Some  relief  may  be  afi^orded  by  a  partial  closure  of  the 
fissure.  This  is  done  by  covering  the  fissure  throughout  its  greater 
extent  with  flaps  of  skin  from  the  abdominal  wall. 

(6)  Double  Bladder. — Double  bladder  is  due  to  a  failure  of  the  two 
parts  of  the  allantois  to  fuse  in  early  fetal  life.  But  few  cases  are 
recorded. 

(c)  Loculate  Bladder. — Projections  are  sometimes  seen  on  the  outer 
surface  of  the  bladder,  formed  by  diverticuli  of  the  bladder  wall.  They 
are  congenital  defects,  and  are  not  to  be  confounded  with  diverticuli 
of  inflammatory  origin.  They  have  been  mistaken  for  supernumerary 
bladders. 


Locations  of  pain  referred  to  the  kidney  (X)  and  bladder  (B). 

2.  Malpositions  and  Malformations.— The  female  bladder  is  subject 
to  malpositions  and  malformations  to  a  far  greater  degree  than  is  that 
of  the  male. 


854  DISEASES  OF  THE  URIXARY  SYSTEM 

The  normal  position  of  the  bladder  is  in  the  median  line.  In  moderate 
distention  the  greatest  diameter  is  transverse,  and  in  extreme  distention 
the  greatest  diameter  is  the  vertical.  The  distended  bladder  may  incline 
considerably  to  the  right  or  left  of  the  median  line  and  may  reach  the 
level  of  the  umbilicus.  The  author  recalls  seeing  in  Vienna  a  post- 
mortem examination  of  a  patient  in  whom  the  bladder  had  been  opened 
and  stitched  to  the  abdominal  wall  in  the  right  lower  quadrant  of  the 
abdomen.  The  bladder,  which  was  greatly  distended,  lay  to  one  side 
of  the  median  line,  and  was  thought  to  be  a  broad  ligament  cyst.  The 
mistake  was  discovered  in  the  postmortem  examination. 

Elevation  of  the  bladder  occurs  when  the  pelvis  is  filled  with  a 
ttimor  mass  and  when  the  uterus  greatly  enlarges  and  extends  into 
the  abdominal  cavity,  dragging  the  bladder  with  it,  even  to  the  level 
of  the  umbilicus.  When  the  elevated  bladder  is  partly  filled  with 
urine  it  forms  a  protruding,  fluctuating  swelling  in  front  of  the  tumor. 

Downward  displacement  of  the  bladder  (cystocele)  is  the  most 
frequent  malposition,  and  is  the  result  of  injury  to  the  pelvic 
floor  and  of  increase  in  the  intra-abdominal  pressure.  It  is  most 
unusual  for  a  cystocele  to  exist  in  a  nullipara.  Occupations  which 
involve  much  standing  and  lifting,  predispose  to  cystocele,  even  in 
nullipara. 

In  slight  degrees  of  descent  the  lower  part  of  the  bladder  is  somewhat 
sunken,  and  in  extreme  cases  the  bladder  becomes  shaped  like  an  hour- 
glass, being  divided  into  an  upper  and  lower  segment  by  the  urethra. 
In  extreme  grades  associated  with  prolapsus  uteri,  the  urethra  may  run 
vertically,  the  external  orifice  pointing  directly  upward.  Virchow, 
Philips,  Braiin,  and  others  have  observed  dilated  ureters  and  hydro- 
nephrosis as  the  result  of  obstruction  to  the  flow  of  urine  through  the 
stretched  and  twisted  ureters. 

The  diagnosis  is  largely  based  upon  the  physical  findings;  the  com- 
plaints of  the  patient  will  give  but  little  clue  to  the  diagnosis.  There 
is  a  frequent  desire  to  urinate,  and  this  is  associated  with  more  or  less 
pain.  Advanced  cases  may  continue  with  little  or  no  disturbance  of 
the  bladder  functions.  A  number  of  cases  of  cystocele  have  been 
reported  in  which  the  passage  of  the  child  was  impeded.  The  patient, 
when  she  is  first  aware  of  the  protruding  vaginal  wall,  regards  it  as 
"falling  of  the  womb."' 

With  the  patient  in  the  lithotomy  position,  the  labia  are  separated 
and  she  is  instructed  to  bear  do"«TL.  The  anterior  vaginal  wall  suddenly 
bulges  into  a  roimded  mass,  which,  if  filled  with  urine,  will  fluctuate 
when  grasped  by  the  fingers.  A  metahic  soimd  placed  in  the  bladder 
will  demonstrate  the  pouching  of  the  bladder  into  the  vaginal  tumor. 

\Mien  a  cystocele  is  observed,  the  examination  is  not  complete  until 
the  position  of  the  uterus,  the  conditions  of  the  pelvic  floot,  and  the 
urine  are  carefully  determined,  because  malpositions  of  the  uterus, 
injuries  to  the  pelvic  floor,  and  chronic  cystitis  are  almost  constantly 
associated  with  cystocele. 

Treatment. — See  Cystocele,  page  294. 


DISEASES  OF  THE  BLADDER  855 

Eversion  of  the  Bladder. — Eversion  of  the  bladder  through  a  dilated 
urethra  is  rarely  observed.  Before  such  an  event  can  occur  there  must 
be  a  relaxed  bladder  wall  and  a  dilated  urethra,  which,  together  with 
an  increase  in  the  abdominal  pressure,  may  produce  the  condition.  A 
sound  passed  through  the  urethra  will  demonstrate  the  absence  of  the 
bladder.  Reducing  the  protruding  mass,  the  bladder  is  restored  to 
its  normal  position.  This  rare  displacement  has  been  observed  in 
infants  and  in  the  aged  more  often  than  in  middle  age.  Pelvic  tumors 
are  often  associated  with  the  displacement  of  the  bladder,  and  demand 
attention  after  the  replacement  of  the  bladder  by  taxis.  Taxis  is  best 
performed  by  placing  the  patient  in  the  knee-chest  position.  After 
replacing  the  bladder,  the  patient  should  be  kept  in  bed  for  several 
days,  with  the  hips  well  elevated.  If  the  urethra  is  greatly  relaxed 
it  may  be  necessary  to  narrow  its  caliber  as  described  on  page  846. 

Hernia  of  the  Bladder. — Hernia  of  the  bladder  through  the  inguinal 
or  femoral  rings  and  through  the  foramen  ovale  has  been  observed. 

3.  Foreign  Bodies. — Winckel  divides  the  foreign  bodies  found  in 
the  bladder  into  those  that  originate  in  the  organ  itself,  those  that  come 
from  other  parts  of  the  body,  and  those  that  are  introduced  from 
without. 

(a)  Foreign  Bodies  Originating  in  the  Bladder  are  in  large  part  vesical 
calculi.  Calculi  may  arise  from  a  precipitation  of  urinary  salts  inde- 
pendent of  the  previous  existence  of  a  foreign  body,  or  they  may  have 
as  nuclei  certain  foreign  elements  introduced  into  the  bladder  from 
without  or  from  the  upper  urinary  tract.  They  are  not  so  common 
in  the  female  as  in  the  male,  because  of  the  shortness  of  the  urethra, 
the  rarity  of  urethral  strictures,  and  the  readiness  with  which  lesions 
of  the  female  bladder  are  cured. 

In  1792  cases  of  vesical  calculi,  found  in  Moscow  by  Dr.  Klein, 
only  4  occurred  in  women.  In  10,000  women,  examined  by  Winckel 
from  1860  to  1884,  in  only  1  did  he  find  calculi.  In  3500  autopsies 
done  upon  women  in  the  Dresden  City  Hospital,  stone  in  the  bladder 
was  found  6  times.  These  statistics  speak  for  the  infrequency  of 
vesical  calculi  in  women. 

The  calculi  are  usually  lodged  in  the  bladder  immediately  back  of 
the  trigone.     Not  infrequently  they  lie  in  the  pouch  of  a  cystocele. 

In  the  only  case  observed  by  the  author  a  cystocele  was  filled  with 
about  twenty  stones,  varying  in  size  up  to  that  of  a  hickorynut.  These 
were  found  in  a  woman,  aged  sixty-five  years.  A  fistulous  communica- 
tion with  the  vagina  had  developed  in  the  cystocele,  and  through  it 
the  stones  were  extracted. 

Vesical  stones  vary  in  number,  size,  color,  consistency,  and  compo- 
sition. They  have  been  known  to  be  as  large  as  a  child's  head. 
Hugenberger  removed  one  weighing  three  and  a  half  pounds. 
Hundreds  of  stones  may  be  found  in  the  bladder.  They  are  composed 
of  phosphates,  urates,  oxalates,  and  rarely  of  cystin. 

(h)  Foreign  Bodies  in  the  Bladder  that  Originate  from  Other  Parts  of 
the  Body  are  the  oxalic  and  uric  acid  calculi  coming  from  the  kidney, 


856  DISEASES  OF  THE   URINARY  SYSTEM 

the  contents  of  ovarian  cysts  which  have  ruptured  into  the  bladder 
(teeth  from  dermoid  cysts  have  formed  the  nucleus  of  stone),  the 
products  of  extra-uterine  pregnancy  following  rupture  of  the  gestation 
sac  into  the  bladder,  fecal  matter  from  an  ulcerated  bowel,  and  finally 
echinococci  may  form  the  nucleus. 

(c)  Foreign  Bodies  in  the  Bladder  Introduced  from  Without  are  portions 
of  catheters,  sutures,  hairpins,  pessaries  which  have  ulcerated  through 
the  vesicovaginal  septum,  toothpicks,  and  the  like. 

The  diagnosis  of  foreign  bodies  in  the  bladder  is  based  upon  the 
patient's  complaint  of  an  irritable  bladder;  later  on  the  clinical  evidences 
of  cystitis,  and,  finally  and  conclusively,  upon  the  finding  of  a  foreign 
body  within  the  bladder  by  palpation  and  inspection,  or  upon  the 
spontaneous  expulsion  of  the  body. 

If  the  body  is  large  it  may  be  palpated  through  the  vagina.  A 
sound  passed  into  the  bladder  will  often  disclose  the  presence  of  a 
foreign  body.  By  inspection  of  the  interior  of  the  bladder,  not  only 
the  presence  of  a  foreign  body  is  determined,  but  also  the  character, 
number,  size,  form,  and  exact  location.  Direct  inspection  is  of  special 
value  when  the  stone  lies  in  a  diverticulum  beyond  the  reach  of  the 
sound.  Fine  gravel,  too  fine  to  be  detected  by  the  sound,  is  also  demon- 
strated by  the  cystoscope.  Not  only  the  presence  of  a  foreign  body, 
but  the  accompanying  cystitis  is  recognized  by  the  aid  of  the  cystoscope. 
Irritation  of  the  bladder  by  the  foreign  body  may  render  the  viscus 
too  sensitive  for  a  cystoscopic  examination  without  general  anesthesia. 

Treatment. — All  foreign  bodies  within  the  bladder  require  immediate 
removal  when  small;  this  may  be  accomplished  through  the  intact 
urethra,  and  when  too  large  for  this  procedure,  they  are  to  be  removed 
through  a  vesicovaginal  or  suprapubic  incision. 

To  remove  a  small  body  through  the  intact  urethra,  a  speculum  is 
introduced  through  the  dilated  urethra.  This  should  be  as  large  as  the 
urethra  will  accommodate  without  danger  of  producing  incontinence. 
Through  a  reflected  light  the  foreign  body  is  located,  and  by  manipulation 
the  foreign  body  is  made  to  engage  in  the  speculum  when  it  is  withdrawn. 
Vesical  calculi  -may  be  crushed  by  forceps  passed  through  the  speculum, 
and  the  fragments  removed  by  forceps  and  irrigation.  In  applying 
the  lithotrite  it  is  best  to  partially  distend  the  bladder  with  water. 
No  attempt  should  be  made  to  remove  large  stones  through  the  urethra 
for  fear  of  producing  incontinence.  If  they  cannot  be  crushed,  they 
are  to  be  removed  per  vaginam  or  through  a  suprapubic  incision;  the 
vaginal  incision  is  preferred  to  the  suprapubic. 

The  vesicovaginal  incision  is  best  made  with  the  patient  in  the 
Sims  position  and  the  anterior  wall  of  the  vagina  exposed  by  a  Sims 
speculum.  A  large  sound  is  introduced  into  the  bladder  and,  made  to 
impinge  against  the  posterior  wall  of  the  bladder  in  the  median  line.  It 
is  then  cut  down  upon  from  the  vaginal  side,  making  an  opening  large 
enough  to  permit  the  introduction  of  the  index  finger,  by  which  the 
bladder  is  explored,  the  foreign  body  located,  and  the  dimensions  noted. 
The  incision  is  then  enlarged  with  the  scissors  to  a  size  sufficient  to 


DISEASES  OF  THE  BLADDER  857 

permit  of  the  extraction  of  the  foreign  body.  After  the  removal  of 
the  foreign  body,  the  incision  is  closed  with  non-absorbable  sutures 
and  a  permanent  catheter  is  introduced  through  the  urethra.  x4t  the 
end  of  five  or  six  days  the  catheter  should  be  removed  and  in  ten  to 
twelve  days  the  patient  may  be  permitted  to  leave  her  bed. 

In  infants  particularly,  and  in  all  cases  in  which  the  vaginal  route 
presents  unusual  difficulties,  also  when  the  stone  is  of  large  size,  the 
suprapubic  route  is  preferred. 

The  bladder  is  distended  with  water  and  a  suprapubic  median 
incision  is  made  two  to  four  inches  in  length,  beginning  at  the  upper 
border  of  the  symphysis  and  extending  upward.  Care  should  be  taken 
to  avoid  opening  into  the  peritoneal  cavity.  "^Yhen  the  bladder  is 
exposed  and  grasped  with  forceps,  a  vertical  incision  is  made  in  the 
median  line  long  enough  to  permit  of  the  delivery  of  the  foreign  body. 
After  the  removal  of  the  foreign  body  the  incision  in  the  bladder  wall 
is  closed  with  interrupted  chromic  catgut  sutures  and  the  abdominal 
wall  closed  in  the  usual  manner.  A  self-retaining  catheter  should  be 
worn  for  five  or  six  days. 

4.  Cystitis. — Cystitis  is  an  inflammatory  lesion  of  the  bladder  due  to 
invasion  of  the  walls  of  the  bladder  by  pathogenic  microorganisms. 

Etiology. — In  2500  postmortem  examinations  of  women,  cystitis  was 
found  68  times  (2.7  per  cent.). 

Virchow  holds  that  the  urine  must  first  become  ammoniacal,  and 
by  its  irritating  effects  cause  the  epithelium  to  become  loosened  before 
bacteria  can  gain  a  lodgement  in  the  bladder  wall.  Under  apparently 
normal  conditions  the  tirine  may  contain  bacteria,  hence  there  must 
exist  a  predisposing  cause  for  cystitis  before  the  bacteria  manifest 
their  pathogenic  properties. 

As  predisposing  causes  of  cystitis  may  be  mentioned  congestion 
due  to  overdistention  of  the  bladder;  the  presence  of  foreign  bodies 
in  the  bladder;  structures  crowding  upon  the  bladder  from  without 
(displaced  uteri,  pelvic  exudates,  and  tumors) ;  traumatisms  sustained 
in  labor  and  surgical  operations;  the  passage  of  catheters  and  sounds; 
ill-fitting  pessaries;  the  irritating  influence  of  internal  remedies,  of 
fluids  injected  into  the  bladder,  and  of  toxins  developed  within  the 
body  in  the  course  of  infectious  diseases  and  intestinal  disturbances. 
Congestion  of  the  bladder  from  any  of  the  above-named  causes  will 
prepare  the  tissues  for  invasion  by  pathogenic  microorganisms. 

The  microorganisms  found  in  the  inflamed  bladder  are  the  staphylo- 
coccus pyogenes  aureus,  albus,  and  citreus;  streptococcus  pyogenes, 
bacfllus  coli  communis,  gonococcus,  bacillus  tuberciflosis,  bacillus 
typhosis,  and  numerous  microorganisms  of  lesser  clinical  importance, 
as,  for  example,  the  bacillus  aerogenes  capsulatus  of  Welch,  diplococcus 
pyogenes  urete,  coccobacillus,  and  the  urobacillus  liquefaciens. 

Not  infrequently  two  or  more  of  the  above-named  bacteria  are 
found  in  the  same  case.  There  is  a  condition  known  as  bactenuria, 
in  which  the  urine  swarms  with  bacteria  in  the  absence  of  any  con- 
siderable amount  of  pus  or  other  foreign  elements. 


858  DISEASES  OF  THE  URINARY  SYSTEM 

The  avenues  by  which  these  microorganisms  enter  the  bladder  are : 
(a)  The  urethra,  which  is  the  most  common  of  all.  Microorganisms, 
which  always  exist  in  large  numbers  in  the  urethra,  vagina,  and  vulva, 
may  be  carried  by  instruments  through  the  urethra  into  the  bladder. 
It  is  possible  for  bacteria  to  pass  through  the  urethra  into  the  bladder 
without  the  introduction  of  instruments.  This  is  notably  true  of  the 
gonococcus. 

(6)  The  kidney,  when  infected,  may  involve  the  bladder  through 
the  medium  of  the  urine.  It  has  been  demonstrated  that  the  urine 
may  convey  pathogenic  microorganisms  to  the  bladder,  and  there 
cause  an  infection  without  deranging  the  kidney.  The  colon  bacillus 
and  tubercle  bacillus  probably  most  often  gain  access  to  the  bladder 
from  the  blood  by  way  of  the  kidney. 

(c)  The  bowel,  when  adherent  to  the  bladder,  may  transmit  the 
colon  bacillus  and  other  microorganisms  to  the  viscus. 

(d)  Inflammatory  areas  surrounding  the  bladder,  and  intimately  con- 
nected with  it,  may  be  the  sources  of  infection,  as,  for  example,  pelvic 
abscesses,  suppurating  dermoid  cysts,  pyosalpinx,  and  perityphlitic 
abscesses. 

(e)  Hematogenous  infection  of  the  bladder  is  not  common,  though 
fully  demonstrated. 

The  following  summary  is  from  Kelly: 

(a)  Cystitis  is  alwaj^s  caused  by  the  presence  of  bacteria. 

(b)  The  mere  presence  of  bacteria  is  not  sufficient  to  cause  a  cystitis ; 
a  further  predisposing  cause  is  necessary. 

(c)  There  are  various  modes  of  entrance  for  bacteria:  through  the 
urethra,  through  the  ureter  from  the  kidney  directly,  from  inflammatory 
areas  in  the  uterus  or  Fallopian  tubes,  and  probablj'  from  the  rectum 
under,  similar  conditions;  still  another  probable  avenue  of  entrance  is 
through  the  blood. 

(d)  Under  favorable  conditions  any  pathogenic  organism  may  give 
rise  to  cystitis. 

Anatomical  Diagnosis. — With  the  exception  of  the  tubercle  bacillus, 
the  anatomical  changes  do  not  differ  essentially  in  the  various  kinds 
of  infections. 

Kelly  classifies  cystitis  as  diffuse,  circumscribed,  and  scattered, 
and  calls  attention  to  the  important  and  often  overlooked  fact  that 
cystitis  is  not  always  a  disease  of  the  entire  mucosa  of  the  bladder, 
but  is  more  often  found  in  patches  with  normal  mucous  membrane 
intervening.  This  fact  speaks  for  the  efficacy  of  direct  applications 
to  the  involved  areas,  rather  than  of  injections,  to  the  entire  surface. 
Both  acute  and  chronic  lesions  are  recognized. 

In  the  acute  stage  the  bloodvessels  are  prominent,  causing  a  swel- 
ling and  reddening  of  the  mucosa;  small  hemorrhages  are  frequently 
seen. 

In  the  chronic  stage  the  reddening  is  less  intense;  the  mucosa  appears 
grayish  and  is  thrown  into  folds.  Papillomatous  elevations  may  appear 
on  the  surface,  and  over  the  surface  may  be  a  deposit  of  pus,  degener- 


DISEASES  OF  THE  BLADDER  859 

ated  epithelium,  microorganisms,  and  salts,  forming  a  false  membrane 
which  adheres  rather  firmly  to  the  mucosa. 

In  cases  of  long  standing,  the  muscular  wall  of  the  bladder  may  be 
involved,  being  greatly  thickened,  and  giving  rise  to  trabeculse  of 
muscle  bundles  intersecting  at  various  angles.  Abscesses  may  develop 
in  the  wall,  and  superficial  ulcers  are  not  infrequently  seen  on  the 
mucosa.  The  entire  mucous  membrane  may  be  thrown  off  in  the 
so-called  exfoliative  cystitis.     (See  Plates  XXXVII  and  XXXVIII.) 

Clinical  Diagnosis. — Frequent,  painful  urination  characterizes  cystitis. 
The  voiding  of  urine  affords  very  little  relief  in  exaggerated  cases.  The 
patient  may  suffer  from  a  constant  desire  to  urinate.  The  amount  of 
urine  voided  may  be  no  more  than  a  few  drops,  and  this  may  be  passed 
every  few  minutes.  It  is  possible  for  cystitis  with  marked  changes  to 
exist  in  the  bladder  wall  without  seriously  disturbing  the  functions  of 
the  bladder.  The  temperature  and  pulse  are  seldom  influenced  unless 
the  urethra  or  kidneys  are  involved.  The  bladder  is  tender  to  pressure, 
and  an  attempt  to  catheterize  or  to  pass  the  sound  into  it  causes  suffering 
and  should  not  be  done  without  local  or  general  anesthesia. 

The  diagnosis  is  made  from  a  history  of  the  above  symptoms,  from 
an  examination  of  the  urine,  and  from  direct  inspection.  The  urine 
is  usually  alkaline  in  reaction,  though  sometimes  acid,  and  contains 
albumin,  pus,  bladder  epithelium,  crystals  ■  of  triple  phosphates,  a 
variety  of  microorganisms,  membranous  shreds,  and  occasionally  some 
blood.  When  the  bacteria  are  found  in  pure  culture,  or  vastly  pre- 
dominate over  other  forms,  they  are  the  probable  cause  of  the  infec- 
tion. The  presence  of  the  gonococcus  or  the  tubercle  bacillus  in  the 
urine  is  conclusive  evidence  of  the  true  underlying  cause. 

The  clinical  distinction  between  the  acute  and  chronic  forms  of 
cystitis  is  in  the  duration  and  intensity  of  the  symptoms.  They  are 
dependent  upon  the  same  underlying  causes. 

The  cystoscopic  diagnosis  of  cystitis  is  often  difficult  and  may  be 
impossible,  but,  as  a  rule,  the  results  are  readily  obtained  and  are 
conclusive.  In  acute  cystitis  the  difficulty  arises  from  the  pain 
caused  by  the  manipulation  of  the  instrument.  Unless  the  indication 
is  urgent,  no  cystoscopic  examination  should  be  made. 

Local  anesthesia  at  the  neck  of  the  bladder  may  suffice.  When 
possible  to  delay  the  examination  the  patient  should  be  confined 
to  her  bed,  and  sitz  baths,  diluent  drinks,  and  sedatives  administered. 
Chronic  cystitis  may  present  equally  great  difficulties  because  of  the 
contracted  bladder  and  the  deposit  upon  the  bladder  wall. 

Acute  cystitis  is  recognized  through  the  cystoscope  by  the  prominence 
of  the  bloodvessels  in  the  mucosa.  This  congestion  of  the  mucosa 
presents  a  variable  shade  of  red,  having  an  irregular  distribution  over 
the  surface.  The  more  acute  the  inflammation  the  deeper  the  color. 
Hemorrhages  into  the  mucous  membrane  are  seen  varying  in  size  from 
a  pinhead  to  a  pea,  and  in  color  from  bright  red  to  almost  black.  They 
are  most  often  located  near  the  mouths  of  the  ureters,  but  may  be 
found  at  any  point  in  the  mucous  surface. 


860  DISEASES  OF  THE  URINARY  SYSTEM 

Chronic  cystitis  presents  a  paler  surface  of  a  grayish  color;  the  blood- 
vessels are  faintly  traceable;  hemorrhagic  areas  are  darker  and  smaller 
than  in  the  acute  stage.  The  surface  has  lost  its  luster  and  presents 
an  irregular  appearance.  The  folding  and  swelling  of  the  mucous 
membrane  may  hide  the  mouths  of  the  ureters,  and  be  so  enormous 
as  to  suggest  the  possible  presence  of  a  newgrowth. 

There  may  be  no  secretion,  and,  again,  the  secretion  may  be  so 
abundant  and  tenacious  as  to  resist  all  efforts  at  removal  by  irrigating. 
Accumulations  of  the  secretion  may  be  mistaken  for  newgrowths. 
Trabeculse  and  diverticula  are  often  seen  in  cystitis,  and  are  largely 
confined  to  inflamed  areas. 

Tuberculous  Cystitis. — It  is  not  sufficient  to  merely  diagnosticate 
cystitis  and  to  distinguish  between  the  acute  and  the  chronic  forms, 
but  it  is  of  the  greatest  importance  to  recognize,  so  far  as  the  present 
methods  of  examinations  will  permit,  the  bacteriological  factors  involved. 
This  is  particularly  true  of  gonorrheal  and"  tuberculous  cystitis,  since 
the  organisms  causing  these  lesions  are  well  known  and  we  are  in 
possession  of  the  means  of  detecting  them. 

Tuberculosis  of  the  bladder  is  caused  by  infection  through  the  blood, 
by  extension  of  a  tuberculous  process  from  the  kidney,  the  genital 
organs,  or  peritoneum.  The  lesion  is  more  often  found  in  early  and 
middle  life,  and  is  more  frequent  in  the  male  than  in  the  female.  It 
may  be  the  primary  infection  in  the  bladder,  or  other  microorganisms 
may  have  previously  invaded  the  bladder.  A  mixed  infection  is 
common.  In  tuberculosis  of  the  kidney,  it  is  possible  for  tubercle  bacilli 
to  pass  through  the  bladder  in  the  urine  for  years  without  infecting 
the  bladder.  As  in  other  forms  of  infection,  the  healthy,  intact  mucous 
membrane  resists  the  invasion  of  the  microorganisms. 

The  ureteral  openings  and  the  trigone  are  the  most  common  seats 
of  tuberculosis.  Grayish  tubercles  are  seen  to  stud  the  mucous  surface, 
and  are  usually  found  in  groups.  Later  the  tubercles  coalesce  and  form 
cheesy  masses,  which  in  turn  break  down  into  lenticular  ulcers  with  a 
flat  base  and  sharp,  undermined,  ragged  borders  within  which  small 
tubercles  are  seen.  The  ulcers  may  perforate  the  bladder  wall  and 
form  fistulous  tracts  leading  to  the  paravesicular  tissue,  rectum,  and 
vagina. 

The  diagnosis  is  based  upon  the  clinical  evidences  of  cystitis,  asso- 
ciated with  the  presence  of  tuberculosis  elsewhere  in  the  body,  par- 
ticularly in  the  kidney,  upon  the  bacteriological  examination  of  the 
urine,  the  cystoscopic  appearance  of  the  bladder,  the  microscopic 
examination  of  excised  pieces  and  scrapings  removed  from  the  bladder 
through  the  cystoscope  or  a  fistulous  opening,  and  upon  inoculation 
experiments.  Unimpaired  general  health  does  not  exclude  the  possible 
presence  of  tuberculosis.  Renal  tuberculosis  mav  closely  resemble 
vesical  tuberculosis.  Only  by  microscopic  examination  and  inoculation 
experiments  with  catheterized  specimens  of  urine  is  it  possible  to 
exclude  renal  tuberculosis.  Careful  and  repeated  examinations  may 
be  required. 


DISEASES  OF  THE  BLADDER  861 

Prophylaxis. — Prophylaxis  is  first  to  be  considered  in  the  management 
of  cystitis.  Many  cases  of  cystitis  can  be  prevented  if  due  care  be 
taken.  In  this  connection  emphasis  must  be  placed  upon  the  neces- 
sary precautions  to  be  taken  in  catheterization. 

In  the  author's  experience,  about  one  case  in  four  that  is  catheterized 
after  operation  suffers  from  painful  and  frequent  urination.  Only  a 
small  percentage  of  these  cases  develop  a  cystitis,  the  hyperemia  or 
inflammation  being  confined  to  the  urethra.  The  author  is  far  from 
convinced  that  all  these  cases  are  preventable,  but  much  can  be  done 
to  limit  the  frequency  of  their  occurrence. 

The  following  factors  in  the  causation  of  postoperative  cystitis  are 
discussed  on  page  857:  traumatism  in  pelvic  operations,  retention  of 
urine,  infection  from  the  catheter.  Their  means  of  prevention  are 
discussed  and  will  not  be  again  referred  to.  We  may,  therefore,  pass 
to  a  discussion  of  the  active  treatment  of  cystitis. 

Treatment  of  Acute  Cystitis. — No  operative  interference  or  topical 
applications  are  permissible  in  the  acute  stage  of  cystitis.  Rest  must 
be  enjoined  so  long  as  the  acute  stage  continues.  Any  local  interference 
would  tend  to  aggravate  the  condition. 

The  patient  keeps  to  her.  bed.  Hot  applications  are  placed  over  the 
hypogastrium,  vaginal  douches  of  sterile  water  are  given  three  or 
four  times  daily,  at  a  temperature  of  110°  F.,  and  continued  for  fifteen, 
to  twenty  minutes.  The  bowels  are  to  be  kept  freely  open,  with  saline 
cathartics  and  rectal  injections.  Ihe  diet  should  be  light  and  nutritious 
and  free  of  all  stimulants.  Pain  when  excessive  should  be  relieved  by 
opiates;  morphine  may  be  given  hypodermically,  or  rectal  suppositories 
of  opium  may  be  inserted.  Urotropin  in  7  grain  doses  may  be  given 
three  or  four  times  daily.    ]Much  relief  is  afforded  by  sitz  baths. 

Treatment  of  Chronic  Cystitis. — When  the  acute  stage  has  passed  into 
the  subacute  or  chronic,  tentative  measures  must  give  way  to  active 
general  and  local  treatment. 

General  Treatment. — General  treatment  will  not  in  itself  suffice 
for  a  cure;  such  treatment  is  at  best  supplementary  to  local  applications 
and  to  surgical  measures.  Of  the  numerous  drugs  prescribed  for  chronic 
cystitis,  the  author  has  largely  depended  upon  urotropin  in  doses  of 
3  to  7  grains,  administered  three  times  daily.  It  is  probable  that  the 
best  results  from  internal  medication  are  derived  from  the  drinking  of 
large  quantities  of  pure  water.  In  this  manner  the  bladder  is  flushed. 
The  author  has  little  regard  for  the  so-called  medicinal  waters.  Salol, 
in  doses  of  3  to  5  grains,  possesses  some  virtue  in  freeing  the  urine  of 
bacteria  and  in  ameliorating  the  disagreeable  symptoms.  The  oils  of 
sandal-wood  and  copaiba,  given  in  capsules  containing  5  to  10  minims, 
are  said  to  give  good  results  in  gonorrheal  cystitis.  To  relieve  irritation, 
Kelly  recommends  zea  mays  (corn  silk),  also  triticum  repens.  It  is 
essential  to  avoid  the  ingestion  of  highly  spiced  foods  and  alcoholic 
drinks.  If  the  urine  is  strongly  acid,  potassium  citrate,  carbonate,  or 
acetate  may  be  given;  and  if  alkaline,  salol  and  benzoate  of  ammonium 
will  correct  the  condition. 


862  DISEASES  OF  THE   URINARY  SYSTEM 

Local  Treatment. — (a)  Irrigation. — The  washing  out  of  the  bladder 
is  a  most  important  adjunct  to  the  other  means  of  treatment,  and 
should  be  employed  when  there  are  large  quantities  of  bacteria,  mucus, 
and  pus. 

While  plain  sterile  water  will  mechanically  cleanse  the  bladder 
in  the  majority  of  cases,  it  is  often  not  so  well  tolerated  as  normal 
salt  solution  or  a  combination  of  normal  salt,  borax,  and  boric  acid. 
Kelly  recommends  these  elements  in  the  proportion  of  1,  2,  and  4 
respectively.  He  lays  special  emphasis  upon  the  distention  of  the 
bladder  with  such  a  solution,  leaving  the  bladder  moderately  distended 
for  a  minute  or  two,  and  gradually  increasing  the  amount  of  fluid 
injected  as  the  patient's  tolerance  is  increased. 

Technic  of  Irrigation. — ^The  patient  lies  cross-wise  of  the  bed,  on  a 
firm  mattress,  or  at  the  end  of  a  table.  Under  the  buttocks  is  a  drain- 
age pad.  The  legs  are  flexed  upon  the  thighs  and  the  knees  supported 
by  an  assistant.  The  region  about  the  urethral  orifice  is  thoroughly 
cleansed  by  sponging  with  boric  acid  solution. 

The  apparatus  required  consists  of  a  sterile  fountain  syringe,  with 
four  or  more  feet  of  rubber  tubing,  at  the  end  of  which  is  inserted  a 
sterile  glass  catheter.  In  order  that  no  air  be  allowed  to  enter  the 
bladder,  the  irrigating  fluid  is  allowed  to  escape  through  the  catheter 
as  the  catheter  is  passed  into  the  bladder.  The  bladder  is  then  filled 
to  the  point  of  beginning  discomfort  to  the  patient.  The  bag  or  funnel 
should  be  held  at  a  level  that  will  favor  a  slow  filling  of  the  bladder. 
When  the  patient  complains  of  the  bladder  becoming  uncomfortably 
full,  the  flow  of  solution  is  checked  by  pinching  the  tube.  After  permit- 
ting the  bladder  to  remain  distended  for  a  minute  or  two,  the  tube  is 
removed  from  the  catheter  and  the  bladder  emptied.  If  the  solution 
does  not  return  clear  the  process  is  repeated  until  it  is  clear.  By 
patiently  pursuing  this  process  day  after  day  it  will  be  found  that  an 
increasing  amount  of  fluid  can  be  retained. 

If  continuous  irrigation  is  desired  a  two-way  catheter  may  be  used 
to  good  effect. 

(6)  Topical  Applications. — A  limited  quantity  of  fluid  may  be 
injected  through  the  urethra  into  the  bladder.  Such  solutions  are 
silver  nitrate  (1  to  2  per  cent.),  protargol  or  argyrol  (5  to  20  per  cent.), 
bichloride  of  mercury  (1  to  10,000  to  1  to  4000),  iodoform  emulsion 
(5  to  10  per  cent.). 

A  syringe  with  a  long  nozzle  is  used  by  which  2  to  4  grams  of  solution 
are  injected  and  permitted  to  remain  in  the  bladder  for  five  to  thirty 
minutes,  depending  upon  the  tolerance  of  the  patient.  These  injec- 
tions are  repeated  two  to  four  times  a  week  over  a  period  of  several 
weeks. 

Direct  topical  applications  will  be  found  to  be  more  accurate  and 
satisfactory.  This  method  is  applicable  to  cases  in  which  the  lesion  is 
limited  in  area.  The  field  to  be  treated  is  exposed  by  the  cystoscope 
through  which  an  applicator  is  directed  and  the  areas  involved  are 
directly  treated  with  silver  nitrate  in  the  strength  of  3  to  5  per  cent. 


DISEASES  OF  THE  BLADDER  863 

These  applications  should  not  be  repeated  oftener  than  two  or  three 
times  a  week.  They  should  not  be  applied  to  an  acutely  inflamed 
surface. 

Surgical  Measures. — Surgical  measures  are  adopted  in  severe  and 
persistent  cases  which  do  not  yield  to  more  conservative  measures. 
This  procedure  should  only  be  adopted  in  obstinate  and  painful  cases, 
for  the  reason  that  the  patient  must  endure  the  disagreeable  effects  of 
incontinence  of  urine  for  several  months. 

The  operation  consists  in  the  formation  of  a  vesicovaginal  fistula,  and 
is  done  for  the  purpose  of  establishing  free  drainage  of  the  bladder  in 
the  state  of  absolute  rest. 

TecJmic  of  Operation. — The  patient  is  placed  in  the  dorsal  position, 
with  the  thighs  well  flexed  upon  the  abdomen.  The  bladder  is  distended 
with  sterile  water  and  a  sound  placed  within  the  bladder  as  a  guide. 
The  sound  is  guided  to  the  base  of  the  bladder  well  back  of  the  ureteral 
openings.  The  anterior  wall  of  the  vagina  is  then  exposed  by  retractors, 
and  with  a  sharp-pointed  knife,  a  buttonhole  is  made  into  the  bladder 
by  cutting  down  upon  the  end  of  the  sound.  The  opening  into  the 
bladder  is  made  about  one  inch  in  length.  The  mucosa  of  the  bladder 
is  then  stitched  to  the  mucosa  of  the  vagina  with  Xo.  1  plain  catgut, 
using  four  interrupted  sutures.  This  will  prevent  too  early  closure  of 
the  fistula. 

A  general  anesthetic  may  not  be  required,  though  it  should  be  given 
when  not  contra-indicated. 

After  establishing  the  fistula,  a  vaginal  douche  should  be  taken  daily 
and  the  external  parts  protected  from  the  irritating  urine  by  keeping 
the  surface  well  smeared  with  zinc  oxide  ointment.  A  vulvar  pad 
made  of  absorbent  material  must  be  worn  continuously.  The  author 
has  tried  in  vain  to  construct  a  receptacle  for  the  escaping  urine  that 
can  be  worn  by  the  patient,  but  has  failed. 

AMien  the  cystitis  has  cleared  up  the  fistifla  may  be  closed  -in  the 
usual  way.     (See  Vesicovaginal  Fistula.) 

Treatment  of  Tuberculous  Cystitis. — Tuberculous  cystitis  demands 
individual  consideration  in  that  the  prognosis  and  treatment  present 
special  problems. 

Every  means  that  will  combat  tuberculosis  of  the  lungs  must  be 
resorted  to  in  these  cases.  Fresh  air,  nutritious  diet,  and  tonics  are 
all  valuable  adjuncts  to  the  local  treatment.  If  adjacent  structures, 
such  as  the  ureters,  kidneys,  and  Fallopian  tubes,  are  likewise  involved, 
efforts  must  first  be  directed  to  their  relief  before  attempting  to 
eradicate  the  affection  in  the  bladder. 

Topical  Applications. — k  5  to  10  per  cent,  iodoform  emiflsion  may 
be  injected  by  means  of  a  syringe,  and  these  injections  repeated  at 
intervals  of  two  to  three  days.  In  a  smafl  percentage  of  cases  a  cure 
has  been  effected,  and  in  a  yet  greater  number  some  degree  of  relief 
has  been  afforded. 

A  more  effective  means  of  treatment  lies  in  the  exposure  of  the 
tuberculous  ulcers  to  view  by  means  of  the  cystoscope  and  applying 


864  DISEASES  OF  THE   URIXARY  SYSTEM 

the  remedy  in  concentrated  form  directly  to  the  lesion.  A  20  to  40 
per  cent,  solution  of  silver  nitrate  may  thus  be  applied. 

More  effective  than  topical  applications  of  caustics  is  the  scraping 
away  of  the  infection  by  means  of  the  curet. 

Curettage  of  the  Bladder. — Before  applying  the  curet  to  the  bladder, 
the  areas  to  be  curetted  are  located  by  a  cystoscopic  examination. 
After  locating  the  lesions  the  bladder  is  irrigated  with  a  mild  antiseptic 
solution.  The  curet  is  then  passed  through  an  endoscope  into  the  blad- 
der; the  index-finger  of  the  left  hand  is  passed  to  the  anterior  wall  of  the 
vagina,  where  it  is  made  to  rest  as  a  support  to  the  base  of  the  bladder. 
The  base  of  the  bladder  is  then  lightly  scraped.  If  lesions  exist  else- 
where the  curet  is  passed  over  the  respective  areas,  after  which  the 
bladder  is  irrigated  with  a  mildly  antiseptic  solution. 

Excision  of  isolated  tuberculous  lesions  may  be  resorted  to  when 
other  methods  have  failed.  This  is  done  through  a  suprapubic  cyst- 
otomy. Through  such  an  incision  the  affected  tissues  are  readily 
excised,  care  being  taken  to  remove  only  the  tuberculous  mucosa  and 
to  leave  all  isolated  healthy  areas  from  which  a  new  mucosa  may  be 
regenerated.  If  the  musculature  of  the  bladder  is  involved,  the  entire 
wall  is  excised  and  the  edges  brought  together  with  catgut  sutures. 
The  suprapubic  incision  is  closed  and  the  bladder  drained  for  five  or 
six  days  through  the  urethra  by  means  of  a  self-retaining  catheter. 

Hyperemia  of  the  Bladder. — Hyperemia,  irritable  bladder,  and 
neuralgia  are  terms  in  common  usage,  and  imply  a  disturbance  of  the 
bladder  functions  with  vascular  congestion  of  the  mucosa.  This 
hyperemia  may  be  diffuse,  but  is  more  often  confined  to  a  definite 
portion  of  the  bladder,  particularly  to  the  trigone.  The  involved 
areas  are  red,  swollen,  and  tender  to  the  touch  of  an  instrument.  There 
is  no'  possible  way  of  distinguishing  such  a  condition  from  a  mild, 
localized  cystitis.  The  symptoms  are  identical.  Hyperemia  of  the 
bladder  shoidd  be  diagnosticated  without  difficulty  by  a  cystoscopic 
examination. 

5.  New-formations  of  the  Bladder. — Tumors  of  the  bladder  are  more 
rarely  found  in  the  female  than  in  the  male.  Nearly  every  variety  of 
tumor,  both  benign  and  malignant,  is  found  in  the  bladder.  Of  the 
benign  tumors  there  are  myoma,  fibroma,  papilloma,  adenoma,  and 
dermoid  cysts,  and  of  the  malignant  tumors,  carcinoma  and  sarcoma. 

Fere  has  shown  the  places  of  predilection  of  tumors  in  a  table  con- 
structed from  the  reports  of  107  cases.  In  the  107  reported  cases,  25 
were  found  in  the  base  of  the  bladder,  17  in  the  posterior  wall,  13  in 
both  the  base  and  walls,  8  close  to  the  left  ureter,  5  near  the  right  ureter, 
2  in  the  anterior  wall,  1  in  the  anterior  and  superior  wall;  12  were 
multiple  and  8  diffuse. 

]\Iore  than  half  the  tumors  of  the  bladder  are  single. 

Myoma. — Myoma  originates  from  the  muscular  wall  of  the  bladder, 
and  is  composed  of  smooth  muscular  fiber  and  a  limited  amount  of 
connective  tissue.  The  tumor  is  sessile  or  pedunculated.  But  few 
cases  are  reported. 


DISEASES  OF  THE  BLADDER 


865 


Fibroma. — Fibroma  usually  appears  as  a  fibrous  polyp  with  a  long, 
slender  pedicle.  The  tumor  is  composed  of  fibrous  tissue.  They  are 
rare. 

Papilloma. — Papilloma  of  a  benign  character  protrudes  into  the 
cavity  of  the  bladder  as  a  wart-like  growth,  with  villous  projections 
on  the  surface  of  the  tumor.  In  the  place  of  villosities  there  may  be 
nodular  projections.  They  are  vascular  and  bleed  freely  to  the  touch. 
A  single  tuft  may  be  found  on  the  trigone,  or  the  entire  inner  surface 
of  the  bladder  may  be  covered.  Its  growth  may  be  slow,  extending 
over  years,  with  but  little  increase  in  size.  The  tumor  is  rarely  as 
large  as  a  child's  fist,  and  is  to  be  regarded  as  the  most  common  of  the 
tumors  of  the  bladder. 


Fig.   603 


Multiple  benign  papilloma  of  the  bladder.     (Watson  and  Cunningham.) 


Adenoma. — Adenoma  of   the  bladder   is  a  rare   new-formation  of 
epithelial  origin.     It  is  sessile  or  pedunculated,  and  seldom  attains  a 
large  size.    The  histogenesis  of  the  growth  is  uncertain. 
55 


866 


DISEASES  OF  THE   URINARY  SYSTEM 


Dermoid  Cysts. — Dermoid  cysts  of  the  bladder  have  been  recorded 
by  Paget  and  Boucher.  Their  existence  has  been  questioned.  Cases 
are  not  wanting  in  which  a  dermoid  cyst  of  the  ovary  has  discharged 
its  contents  into  the  bladder  and  there  formed  a  nucleus  for  vesical 
calculi. 

Carcinoma. — Carcinoma  of  the  bladder  is  primary  or  secondary.  In 
secondary  carcinoma  the  primary  seat  of  the  lesion  is  usually  in  the 
cervix,  having  spread  thence  to  the  bladder  by  continuity  of  tissue. 


Fig.   604 


Carcinoma  of  the  bladder.     (Watson  and  Cunningham.) 

It  exists  as  a  vegetating  villous  growth  or  as  a  diffuse  infiltration, 
and  is  usually  multiple.  It  bleeds  freely  to  the  touch  and  is  exceedingly 
friable.  Ulceration  quickly  follows  upon  infiltration,  and  there  is  a 
peculiar  tendency  on  the  part  of  the  growth  to  remain  localized  for  a 
surprisingly  long  time.  Secondary  growths  are  frequently  found  near 
the  primary  lesion. 

Sarcoma.^ — Sarcoma  appears  in  the  female  bladder  more  frequently 
than  in  the  male,  and  is  found  at  any  period  of  life  from  childhood  to 
the  postclimacteric  period.  These  growths  are  said  to  be  prone  to 
extend  through  the  urethra  and  to  appear  at  the  vulva. 

Diagnosis  .^ — The  diagnosis  of  tumors  of  the  bladder  is  determined 
by  palpation  and  inspection.  The  clinical  signs  in  the  early  stage  are 
similar,  whatever  the  character  of  the  growth.    All  tumors  show  more 


DISEASES  OF  THE  BLADDER  867 

or  less  tendency  to  bleed.  Hemorrhage  is  the  most  characteristic 
symptom.  The  bleeding  is  increased  during  the  period  of  menstrual 
congestion,  and  has  been  observed  to  be  greatest  in  the  night.  Pain 
may  be  present  in  the  benign  as  well  as  in  the  malignant  growths, 
though  seldom  to  so  great  a  degree,  but  is  singularly  absent  in  many 
cases.  Late  in  the  course  of  the  lesion,  emaciation  and  cachexia  develop 
in  cases  of  malignant  growths,  and  serve  to  distinguish  these  from 
benign  new-formations. 

Examination  of  the  urine  is  of  little  value  in  distinguishing  tumors 
of  the  bladder  from  calculi  or  cystitis.  Evidences  of  cystitis  will 
usually  be  found  in  the  urine,  but  this  is  not  invariably  the  case  even 
in  the  presence  of  large  tumors  of  long  standing.  On  the  contrary, 
the  bladder  wall  may  present  a  normal  appearance  or  may  be  anemic. 
The  loss  of  blood  may  be  so  great  as  to  produce  a  high  degree  of  anemia 
and  exhaust  the  strength  of  the  patient.  The  presence  of  cylindrical 
cells  in  the  urine  is  regarded  by  some  authorities  as  conclusive  evidence 
of  the  existence  of  a  papillary  gro-v\i;h. 

Palpation  reveals  the  presence  of  a  foreign  growth  if  it  is  sufficiently 
large.  It  may  be  possible  to  detect  the  infiltration  of  a  malignant  growth 
in  the  neighboring  tissues.  Two  fingers  inserted  into  the  vagina  and 
the  other  hand  on  the  abdomen  may  engage  the  tumor.  A  soft,  pedun- 
culated gro'^'lh  may  elude  detection  by  this 'method.  Such  soft,  ped- 
unculated growths  and  all  small  tumors  can  be  detected  only  by  a 
cystoscopic  examination.  Direct  palpation  of  the  tumor  through  the 
urethra  is  an  obsolete  method. 

Direct  inspection  gives  positive  evidence  of  the  presence  of  a  tumor, 
of  its  size,  form,  color,  and  location,  of  the  number  of  gro^'ths,  whether 
pedunculated  or  sessile,  ulcerated  or  intact;  also,  as  to  whether  there 
exists  a  cystitis  and  the  extent  of  the  inflammatory  complications. 
Through  the  speculum  a  piece  of  the  gro^-th  may  be  removed  for 
microscopic  examination. 

Treatment. — The  treatment  in  all  these  cases  is  operative  when  it 
is  possible  to  remove  the  gro-^-th. 

These  cases  require  careful  investigation  before  deciding  upon  an 
operation,  because  of  the  frequency'  with  which  they  are  found  malignant 
and  beyond  the  possibility  of  removal,  and  the  common  occurrence  of 
serious  complications,  such  as  general  debility,  nephritis,  and  cystitis. 
It  is  therefore  imperative  to  make  a  thorough  preliminary  examination 
of  the  urine,  to  make  one  or  more  cystoscopic  examinations,  and  to 
note  the  general  condition  of  the  patient  before  deciding  upon  operative 
interference. 

Having  decided  to  remove  the  growth,  the  avenue  through  which 
the  tumor  is  to  be  removed  must  be  chosen.  The  choice  hangs  upon 
the  size  and  number  of  the  growths,  the  location,  and  the  presence  or 
absence  of  a  pedicle. 

The  following  channels  are  available:  (a)  The  dilated  urethra; 
(b)  a  vaginal  incision  into  the  base  of  the  bladder;  (e)  a  suprapubic 
incision;  (d)  by  symphyseotomy;  (e)  by  cystectomy. 


868  DISEASES  OF  THE   URINARY  SYSTEM 

(a)  Removal  of  the  Tumor  through  a  Dilated  Urethra. — In  order  to 
remove  a  tumor  of  the  bladder  through  a  dilated  urethra,  the  tumor 
must  be  small  and  pedunculated.  The  urethra  must  be  dilated  to  the 
maximum  degree,  which  in  ordinary  cases  is  that  of  a  Xo.  2  dilator.  In 
order  to  obtain  such  a  degree  of  dilatation,  it  may  be  necessary  to  incise 
the  external  orifice  posteriorly  to  prevent  tearing.  A  large  urethral 
speculum  may  then  be  introduced  through  which  the  tumor  may  be 
severed  from  its  attachment  to  the  bladder  and  removed  through  the 
urethroscope.  A  galvanocautery  loop  is  best  for  the  purpose.  To 
sever  the  pedicle  without  cauterizing  might  lead  to  serious  hemorrhage. 

Only  benign  growths  are  so  treated,  and  hence  the  necessity  of  a 
careful  microscopic  examination  of  these  tumors  after  their  removal. 
If  found  to  be  malignant,  a  liberal  excision  of  the  bladder  wall  at  the 
base  of  the  tumor  must  follow,  and  this  is  done  either  through  a  supra- 
pubic or  vaginal  incision. 

(b)  The  tumor  may  be  removed  through  a  vaginal  incision  when  favor- 
able conditions  exist.  Tumors  of  the  anterior  wall  of  the  bladder  are 
easiest  reached  through  this  avenue.  The  work  is  greatly  facilitated 
by  a  lax  vaginal  outlet. 

The  tumor  is  first  located  by  the  use  of  the  cystoscope.  The  patient 
is  best  placed  in  the  knee-chest  position,  though  the  dorsal  position  may 
be  employed.  A  sound  is  introduced  into  the  bladder,  and  against  the 
sound  the  incision  is  carried  in  the  median  line  of  the  anterior  vaginal 
wall.  The  opening  is  made  sufficiently  large  to  expose  the  tumor 
to  view.  The  tumor  is  grasped  by  tenaculum  forceps  and  drawn  into 
the  incision,  and  with  it  the  bladder  wall  at  the  basal  attachment  of 
the  growth.  The  tumor  is  then  excised,  and  if  there  is  doubt  as  to  the 
character  of  the  growth,  a  portion  of  the  bladder  wall  may  be  excised, 
together  with  the  growth.  Sutures  are  then  placed  to  close  the  wound, 
and  drainage  established  through  the  urethra  by  the  insertion  of  a 
self-retaining  catheter. 

Kelly  recommends  transfixing  the  bladder  wall  at  a  distance  from 
the  tumor  by  one  or  more  sutures  to  prevent  the  retraction  of  the 
bladder  in  the  act  of  excision. 

(c)  Removal  of  the  tumor  through  a  suprapubic  incision  is  most  satis- 
factory when  the  tumor  is  large  or  multiple  and  when  it  is  necessary 
to  excise  a  considerable  part  of  the  bladder  wall.  Through  the  supra- 
pubic incision  the  bladder  is  exposed  and  opened,  if  possible,  without 
entering  the  peritoneal  cavity.  It  is  particularly  dangerous  to  enter 
the  peritoneal  cavity  in  the  presence  of  cystitis. 

A  vertical  incision  two  or  three  inches  in  length  is  made  in  the  median 
line  from  the  symphysis  pubis  upward.  The  vault  of  the  bladder  is 
exposed  upon  entering  the  prevesical  space  by  crowding  the  peritoneum 
upward.  A  vertical  incision  is  then  made  into  and  through  the  anterior 
wall  of  the  bladder.  This  incision  is  made  long  enough  to  excise  and 
deliver  the  tumor. 

It  is  well  to  conserve  every  portion  of  healthy  mucous  membrane 
even  to  the  smallest  islets,  in  order  to  facilitate  the  regeneration  of 


DISEASES  OF  THE   URETERS  869 

the  mucosa.  Whenever  possible  the  defect  in  the  mucosa  occasioned 
by  the  removal  of  the  tumor  should  be  closed  by  sutures  of  catgut. 
When  the  tumor  involves  the  musculature  of  the  bladder  wall,  the 
entire  wall  may  be  sacrificed  to  a  point  well  beyond  the  circumference 
of  the  tumor.  The  greater  part  of  the  bladder  may  be  removed  without 
destroying  its  function.  Interrupted  chromic  catgut  sutures  are  used 
in  closing  the  wound.  When  the  peritoneum  has  been  incised,  the 
rent  must  be  carefully  closed  with  a  running  suture  of  plain  catgut. 
The  original  incision  into  the  bladder  is  then  closed  w^ith  interrupted 
sutures  of  chromic  catgut  and  the  incision  through  the  abdominal 
wall  closed  in  the  usual  manner.  A  self-retaining  catheter  is  placed 
in  the  urethra  for  the  purpose  of  free  drainage  of  the  bladder;  it  may 
be  removed  at  the  end  of  five  days. 

(d)  Symphyseotomy . — This  operation  is  suggested  by  Kelly  for  the 
removal  of  tumors  at  the  neck  of  the  bladder.  He  finds  little  use 
for  it. 

(e)  Cystectomy. — The  removal  of  the  entire  bladder  has  been  done 
in  advanced  malignant  growths.  It  is  questionable  if  the  operation 
is  justifiable. 

DISEASES  OF  THE  URETERS 

Anatomy  and  Physiology. — Anatomy. — The  ureters  lie  behind  the 
abdominal  and  pelvic  peritoneum,  and  are  slightly  movable,  flattened 
cords,  extending  from  the  kidney  to  the  bladder.  Under  normal  con- 
ditions they  run  symmetrically  in  an  irregular  curved  course  on  either 
side.  The  average  length  is  ten  to  twelve  inches,  the  left  being  slightly 
longer  than  the  right  because  of  the  higher  position  of  the  left  kidney. 

There  is  no  variation  in  the  diameter  of  the  ureter  except  at  either 
end,  where  it  distends  above  into  the  funnel-shaped  pelvis  and  below 
into  the  ureteral  prominence.    The  average  diameter  is  5  mm. 

The  ureters  are  traced  through  the  pelvis  in  a  sigmoid  course.  They 
lie  close  to  the  posterior  lateral  wall  of  the  pelvis  beneath  the  peritoneum 
and  near  the  internal  iliac  artery.  From  this  point  they  turn  forward, 
passing  underneath  the  uterine  artery  at  the  base  of  the  broad  ligament, 
half-way  between  the  cervix  and  the  pelvic  wall.  They  then  run  parallel 
to  the  upper  anterior  vaginal  wall  and  enter  the  bladder  at  the  upper 
angle  of  the  trigone.  Through  the  bladder  wall  the  ureters  run  obliquely 
forward  and  inward. 

The  course  of  the  abdominal  portion  of  the  ureter,  including  that 
part  running  from  the  kidney  to  the  brim  of  the  pelvis,  passes  forward 
in  a  curved  direction  over  the  psoas  muscle  to  the  brim  of  the  pelvis. 
The  ovarian  veins  and  artery  join  the  ureter  at  a  midpoint  in  its  course 
through  the  abdomen.  On  the  left  side  it  lies  behind  the  colon  above 
and  the  sigmoid  below;  on  the  right  side  it  lies  behind  the  caput  coli 
and  the  ascending  colon. 

Physiology. — The  ureters  are  not  merely  passive  in  conveying  the 
urine  from  the  kidney  to  the  bladder.    A  peristaltic  wave  travels  from 


870  DISEASES  OF  THE   URINARY  SYSTEM 

above  downward  two  or  three  times  each  minute,  imparting  to  the 
ureters  a  vermicular  movement  and  forcing  the  urine  onward. 

Methods  of  Examination. — Four  methods  of  examining  the  ureters 
are  in  general  use:  palpation,  inspection,  catheterization,  and 
sounding. 

Palpation. — It  is  possible  to  palpate  the  pelvic  portion  of  the  ureter 
through  the  vagina  and  rectum.  The  abdominal  portion  of  the  ureter 
cannot  be  palpated  without  making  an  incision  into  the  abdomen  or 
lumbar  region. 

In  palpating  the  pelvic  portion  of  the  ureter,  the  bladder  and  rectum 
must  be  empty,  all  clothing  constricting  the  waist  must  be  removed 
and  the  patient  placed  in  the  lithotomy  position. 

The  index  finger  is  inserted  high  in  the  vaginal  fornix  near  the  side 
wall  of  the  pelvis.  Stroking  the  vaginal  wall  downward  and  backward, 
the  ureter  is  felt  as  a  slender  cord  which  slips  away  from  the  finger. 
That  portion  leading  from  the  base  of  the  broad  ligament  to  the  bladder 
is  most  easily  felt.  The  size,  consistency,  mobility,  and  direction  of 
the  ureter  serve  to  identify  it  in  a  vaginal  examination. 

The  tendinous  arch  of  the  levator  ani  muscle  must  not  be  mis- 
taken for  the  ureter,  nor  must  the  obturator  vessels  and  nerve.  Only 
when  the  abdominal  walls  are  extremely  thin  can  the  ureter  be  pal- 
pated at  the  pelvic  brim,  about  one  and  a  quarter  inches  to  the  right 
or  left  of  the  promontory  of  the  sacrum.  When  the  ureter  is  diseased 
the  line  of  tenderness  will  serve  as  a  guide. 

Through  the  empty  .rectum,  and  preferably  under  anesthesia,  the 
ureter  can  be  traced  through  the  pelvis,  the  left  being  more  accessible 
than  the  right.  Guided  by  the  pulsations  of  the  internal  iliac  artery,  and 
beginning  at  the  bifurcation  of  the  common  iliac  and  tracing  downward, 
the  finger  detects  a  flat,  yielding  cord  running  downward  and  forward. 
The  larger  and  more  resisting  the  ureter,  the  more  easily  is  it  palpated. 
A  catheter  or  bougie  placed  within  the  ureter  to  serve  as  a  guide  will 
facilitate  the  outlining  of  the  ureter. 

Inspection. — No  portion  of  the  ureter  can  be  inspected  without  an 
incision  except  that  portion  lying  in  the  bladder  wall  which  is  recognized 
through  the  cystoscope  as  the  ureteral  prominence.  With  the  abdomen 
open,  the  lower  abdominal  portion  and  the  upper  pelvic  portion  of  the 
left  side  may  be  inspected  by  drawing  the  sigmoid  toward  the  median 
line.  It  is  possible  to  lay  bare  the  abdominal  portion  of  the  ureter  by 
a  lateral  incision,  drawing  the  ascending  or  descending  colon  to  the 
median  line.  In  this  way  the  peritoneal  cavity  is  not  opened.  The 
ureter  is  found  lying  upon  the  psoas  muscle. 

Catheterization. — Both  palpation  and  inspection  are  of  minor  impor- 
tance as  means  of  investigating  the  ureters.  Little  can  be  positively 
demonstrated  by  these  methods.  By  the  ureteral  catheter  we  may 
diagnosticate  to  a  certainty  the  patency  of  the  ureter,  the  existence 
of  ureteral  calculi,  foreign  growths,  strictures,  hydroureter,  pyoureter, 
and  many  of  the  lesions  of  the  kidney  to  be  considered  later. 

The  urine  from  either  kidney  may  be  collected  without  mixing  with 


DISEASES  OF  THE   URETERS 


871 


that  of  the  opposite  kidney  or  with  the  foreign  elements  in  the  bladder 
and  urethra. 

By  the  Nitze  method  the  catheter  is  introduced  through  the  canal 
in  the  instrument.  The  usual  technique  of  a  cystoscopic  examination 
is  carried  out. 


Fig.  605 


Simultaneous    catheterization    of    the    urctcirs.     Tlie 
separate  sterile  tubes  and  for  an  indefinite  period. 


iiriiif  iiiaj    l;e  colicfted  frnm  either  kidney  in 
The  above  method  is  suggested  by  Kelly. 


In  the  Kelly-Pawlik  method  and  preferably  in  the  elevated  lithotomy 
position,  as  advised  by  Webster  and  Pryor  (see  Fig.  597),  the  catheter 
is  directed  through  an  endoscope  after  a  thorough  inspection  of  the  blad- 
der. In  this  method  the  instruments  employed  are  conical  urethral  dila- 
tors, obturator,  specula  ranging  in  size  from  8  to  10,  head  mirror,  natural 
or  artificial  light,  an  evacuator,  searcher,  long,  curved  mouse-toothed 
forceps,  and  a  flexible  ureteral  catheter.  For  special  purposes  there 
may  be  added  hard-rubber  bougies,  a  metal  ureteral  catheter,  and  a 
series  of  dilating  catheters.    After  thoroughly  inspecting  the  bladder, 


872  DISEASES  OF  THE   URINARY  SYSTEM 

as  advised  by  Kelly,  the  ureteral  orifices  are  located  by  what  is  called 
a  searcher.  ^Yhen  no  difficulty  is  experienced  in  locating  the  ureteral 
orifice  or  prominence,  the  searcher  may  be  dispensed  with  and  the 
catheter  at  once  directed  to  the  ureter.  A  metallic  searcher  is  made 
to  lightly  impinge  against  the  mucous  membrane  in  the  supposed 
location  of  the  ureteral  orifice.  No  force  is  to  be  used  for  fear  of  per- 
forating the  bladder. 

The  searcher  separates  the  lips  of  the  orifice,  which  now  presents  a 
dark,  rounded  opening,  and  is  allowed  to  drop  into  the  ureter  by  its 
own  weight.  It  serves  as  a  guide  to  the  catheter,  which  is  directed  to 
the  ureteral  orifice.  As  the  catheter  enters  the  ureter  the  searcher  is 
withdrawn  by  an  assistant. 

A  flexible  catheter  has  many  advantages  over  one  made  of  metal 
or  non-fiexible  rubber.  It  readily  follows  the  course  of  the  ureter 
to  the  pelvis  of  the  kidney,  and  there  is  little  danger  of  injuring  the 
ureter.  ^Mien  it  is  desired  to  catheterize  the  ureter  without  entering 
the  pelvis  of  the  kidney,  a  shorter  catheter  may  be  emploj'ed,  one 
measuring  twelve  inches,  whereas,  it  would  require  a  catheter  twenty 
inches  in  length  to  extend  to  the  kidney.  It  is  essential  that  the  catheter 
have  a  perfectly  smooth  surface  and  a  blunt,  rounded  end  with  an  oval 
eye  near  the  tip.  A  wire  stylet  is  required  to  give  stiffness  to  the 
catheter  as  it  is  forced  through  the  ureter. 

When  the  bladder  can  be  inspected  without  an  anesthetic  it  is  usually 
possible  to  introduce  a  catheter  without  causing  great  discomfort. 

It  is  important  to  thoroughly  sterilize  the  catheters  both  before  and 
after  using.  All  foreign  particles  must  be  removed  from  the  lumen 
of  the  catheter.  This  can  be  done  by  means  of  a  stylet  and  by  forcibly 
injecting  water  through  the  catheter.  They  should  always  be  kept 
straight,  for  when  allowed  to  roll  up  the  varnish  cracks  and  chips  off. 
When  both  ureters  are  to  be  catheterized,  the  speculum  is  withdrawn 
and  reinserted  beside  the  first  catheter.  When  one  ureter  is  catheterized 
and  there  is  difficulty  in  passing  a  catheter  into  the  other  ureter,  a 
fairly  accurate  method  of  separately  collecting  the  urine  is  found  in 
completely  emptying  the  bladder,  after  which  a  large  catheter  is  placed 
in  the  urethra.  All  urine  collected  in  the  bladder  while  the  ureteral 
catheter  is  in  place  is  assumed  to  come  from  the  opposite  kidney, 
and  especially  is  this  true  when  the  separate  collections  differ  in 
character. 

^Mien,  on  account  of  an  infected  bladder,  it  is  inadvisable  to  pass  a 
catheter  into  the  ureter,  Kelly  advises  collecting  a  few  drops  of  urine 
directly  from  the  ureteral  openings  by  an  instrument  which  he  has  con- 
structed for  the  purpose.  This  amount  will  serve  for  a  microscopic 
examination.  When  the  ureter  is  tortuous  or  the  caliber  is  constricted, 
it  may  be  impossible  to  introduce  a  flexible  catheter.  Here  a  metal 
catheter  will  be  of  service,  but  must  be  used  with  caution  for  fear  of 
injuring  the  ureter. 

Bougies  made  of  hard  rubber,  two  millimeters  in  diameter  and 
twenty  inches  in  length,   are  of  service  in  locating  ureteral  calculi 


DISEASES  OF  THE  URETERS  873 

and  in  dilating  strictures  in  the  pelvic  portion  of  the  ureter.  It  is 
possible  to  push  the  bougies  into  the  pelvis  of  the  kidney  without 
inflicting  injury.  A  bulbous  enlargement  is  placed  about  seven  milli- 
meters back  of  the  point.  These  bulbs  vary  in  size  from  a  little  more 
than  the  diameter  of  the  instrument  to  four  millimeters. 

Kelly  has  ingeniously  devised  a  wax  tip  for  the  bougies,  by  which 
he  is  enabled  to  locate  calculi  in  the  ureter  and  pelvis  of  the  kidney. 
Longitudinal  grooves  are  made  on  the  sides  of  the  tip  for  the  purpose 
of  retaining  the  dental  wax.  A  silk  renal  catheter  tipped  with  wax 
will  serve  the  purpose  equally  well.  The  scratch  marks  made  by  the 
calculi  are  seen  under  a  low  magnifying  glass.  When  the  x-rays  fail 
to  detect  the  stone  it  may  be  possible  to  locate  it  by  wax-tipped  bougies. 

Kelly  gives  the  following  summary  in  a  recent  article  on  "Scratch 
Marks  on  the  Wax-tipped  Catheter  in  the  Diagnosis  of  Stone  in  the 
Kidney  or  Ureter:" 

(a)  The  scratch  marks  afford  a  valuable  confirmation  of  the  findings 
of  the  a:-ray  plates. 

(6)  The  wax-tipped  catheter  serves  to  distinguish  phleboliths  about 
the  vault  of  the  vagina  and  in  the  pelvic  veins  from  ureteral  calculi. 

(c)  In  the  cases  of  stout  women,  in  which  the  a:-ray  findings  are 
unsatisfactory  and  the  repeated  use  of  the  a:-ray  is  dangerous. 

(d)  In  cases  of  uric  acid  and  uratic  calculi,  i-n  which  the  a:-ray  shadow 
is  faint,  leaving  doubt  as  to  the  diagnosis. 

(e)  In  extemporized,  hurried  investigations,  when  the  .r-ray  apparatus 
is  not  conveniently  accessible,  and  more  especially  in  retrograde 
catheterization  from  the  pelvis  of  the  kidney  downward  in  the  course 
of  a  renal  operation,  to  determine  whether  there  are  any  calculi  lodged 
in  the  ureter. 

(/)  In  fibrous  or  old  inflammatory  thickenings  about  the  renal  pelvis 
which  give  a  shadow  on  the  photographic  plate  exactly  like  a  stone. 

Examination  of  the  Urine  Collected  from  the  Ureters.^ — Following  the 
suggestions  of  Kelly  five  things  are  inquired  into  in  making  a  thorough 
examination  of  the  urine  collected  directly  from  the  ureter  and  kidney. 

1.  The  amount  of  fluid  escaping  at  once  upon  the  introduction  of 
the  catheter. 

2.  The  rate  of  flow  during  catheterization. 

3.  Physical  properties,  specific  gravity. 

4.  Chemical  properties. 

5.  Bacteriological  condition. 

The  following  points  are  observed  in  securing  separated  urines 
(Kelly): 

1.  The  exact  time  of  introduction  of  each  catheter  is  noted. 

2.  The  time  of  withdrawal  is  noted  and  also  written  on  a  card, 
giving  the  exact  duration  of  the  flow. 

3.  The  exact  amount  of  secretion  coUected  in  the  test-tube  is  noted. 

4.  It  is  well  to  compare  the  rate  of  secretion,  determined  by  noting 
the  amount  of  flow  in  a  given  unit  of  time,  say  from  five  to  fifteen 
minutes  or  longer,  with  the  entire  amount  passed  in  the  twelve  hours 


874  DISEASES  OF  THE  URINARY  SYSTEM 

during  which  the  examination  is  made.  If  the  amount  secured  is  too 
small  or  too  large,  the  error  may  be  rectified  in  this  way.  A  nervous 
patient,  for  example,  will  sometimes  pass  an  excessive  amount  through 
the  catheter. 

5.  An  analysis  of  each  specimen  of  urine  is  made,  investigating  its 
physical,  chemical,  microscopic,  and  bacteriological  characters.  Special 
attention  must  be  paid  to  the  urea  as  the  most  important  representa- 
tive of  the  physiological  activity  of  the  kidney. 

Dangers  Involved  in  the  Catheterization  of  the  Ureter. — 1.  Direct 
injury  to  the  mucous  membrane  of  the  ureter  and  bladder,  thereby 
creating  an  atrium  for  infection. 

2.  Ureteral  fever,  not  unlike  urethral  fever,  caused  by  the  passage  of 
the  urethral  catheter. 

3.  Cicatrization  of  the  ureteral  opening  into  the  bladder  following 
upon  trauma  produced  by  the  catheter. 

4.  Breaking  off  a  piece  of  the  catheter  in  the  ureter. 

5.  Infection  of  the  ureter  and  kidneys,  possibly  leading  to  a  fatal 
issue. 

In  view  of  these  dangers  the  indiscriminate  use  of  the  ureteral 
catheter  is  to  be  deprecated.  It  should  be  used  only  as  a  last  resort, 
and  with  extreme  caution. 

Congenital  Anomalies  in  the  Development  of  the  Ureters. — 

1.  Absence  of  one  or  both  ureters. 

2.  Occlusion  of  part  or  all  of  the  lumen. 

3.  Double  ureter. 

4.  Ectopic  ureteral  orifice. 

5.  Dilatation  of  a  partially  occluded  ureter. 

6.  Bending  and  twisting  of  the  ureter. 

1 .  Absence  of  One  or  Both  Ureters  is  usually  associated  with  an  absence 
of  the  corresponding  kidney. 

2.  Occlusion  of  Part  or  All  of  the  Lumen  of  the  ureter  is  associated 
with  atrophy  and  cystic  degeneration  of  the  corresponding  kidney. 

3.  A  Double  Ureter,  while  not  often  found,  is  the  commonest  of  all 
congenital  defects  of  the  ureter.  The  ureter  may  be  double  in  any 
portion  of  its  course  or  may  begin  in  separate  and  distinct  pelves  of 
the  kidney  and  open  separately  into  the  bladder.  A  double  ureter 
may  be  unilateral  or  bilateral.  The  condition  has  no  clinical  significance. 
The  clinical  diagnosis  is  inferred  by  the  discovery  of  two  separate  and 
distinct  ureteral  openings  into  the  bladder  and  by  the  passage  of 
bougies  and  catheters  into  each  of  the  ureters. 

-  4.  An  Ectopic  Ureteral  Orifice  presents  at  a  point  outside  the  bladder. 
Very  often  this  is  found  in  the  urethra  and  vagina.  Incontinence  of 
urine  is  the  complaint  of  the  patient.  The  diagnosis  is  based  upon 
direct  inspection  first  of  the  vulva,  next  of  the  vagina  through  a  specu- 
lum, of  the  urethra  through  a  urethroscope,  and,  finally,  of  the  bladder 
through  a  cystoscope.  The  opening  will  be  recognized  as  ureteral 
by  seeing  an  intermittent  flow  of  urine  pass  from  it.  To  determine 
whether  there  is  a  second  ureteral  opening  on  the  same  side,  a  cystoscopic 


DISEASES  OF  THE   URETERS 


875 


examination  is  made.    A  catheter  or  bougie  passed  into  the  opening 
will  be  directed  to  the  corresponding  kidney. 


Prolapse  of  right  ureteral  orifice.     (Tandler  and  Halban.) 


876  DISEASES  OF  THE   URINARY  SYSTEM 

Treatment. — The  operation  consists  in  dissecting  the  ureteral  end 
from  its  bed  and  directing  it  into  the  bladder.  Another  procedure 
consists  in  making  a  suprapubic  incision  into  the  bladder  and  establish- 
ing a  communication  between  the  bladder  and  ureter;  this  is  to  be 
followed  by  ligating  the  distal  end  of  the  ureter  and  closing  the  supra- 
pubic incision.  Before  any  operation  is  attempted  it  is  essential  to 
determine  the  possible  presence  of  a  double  ureter.  If  two  ureters 
are  found  to  emerge  from  a  single  pelvis  of  the  kidney  and  one  opens 
into  the  bladder,  and  the  other  is  external  to  the  bladder,  all  that  is 
required  is  ligature  of  the  accessory  ureter. 

5.  Dilatation  of  a  Partially  Occluded  Ureter  is  a  rare  finding.  The 
corresponding  kidney  becomes  atrophied  and  cystic  unless  there  is 
an  additional  outlet  to  the  urine. 

6.  Bending  and  Twisting  of  the  Ureter  is  associated  with  hydroneph- 
rosis, which,  in  time,  may  result  in  complete  cystic  degeneration  of 
the  kidney. 

Inflammation  of  the  Ureter. — Ureteritis  rarely  exists  apart  from  a 
similar  involvement  of  the  bladder  or  kidney,  and  is  usually  secondary 
to  these  lesions. 

Etiology. — Ureteritis  arises  from: 

1.  Extension  downward  from  the  kidney. 

2.  Extension  upward  from  the  bladder. 

3.  Foreign  bodies  lying  within  the  ureter. 

Primary  ureteritis  is  rare  and  probably  only  arises  as  the  result  of 
injury  by  a  ureteral  catheter  or  stone. 

Secondary  ureteritis  arises  from  extension  downward  from  the  kidney 
or  upward  from  the  bladder. 

Predisposing  causes,  confined  to  the  pelvis,  are  cancer  and  fibroid 
tumors  of  the  uterus,  the  pregnant  uterus,  and  pelvic  inflammatory 
lesions  originating  in  the  genito-urinary  tract. 

]Morris  says  that  pregnancy  may  be  the  starting-point  of  uretero- 
pyelitis  without  the  development  of  cystitis. 

The  streptococcus,  staphylococcus,  and  gonococcus  infections  almost 
invariably  begin  in  the  urethra  or  bladder  and  extend  upward  to  the 
ureter  and  kidney.  . 

It  is  a  matter  of  common  observation  that  an  infection  may  be 
conveyed  from  the  bladder  to  the  kidney  without  leaving  an  evident 
lesion  in  the  ureters,  and  it  is  also  observed  that  the  secretions  from 
the  infected  kidney  may  continuously  bathe  the  mucosa  of  the  ureters 
without  infecting  them,  and  yet  infect  the  bladder. 
~  Diagnosis. — The  diagnosis  of  ureteritis  as  an  independent  lesion  is 
seldom  made;  the  clinical  picture  is  usually  involved  in  a  cystitis  or 
pyelonephritis.  The  predominant  symptoms  are  usually  those  of 
pyelitis  or  cystitis. 

Pain  and  tenderness  along  the  course  of  the  ureter  are  the  most 
characteristic  clinical  manifestations  of  ureteritis.  Frequent  urination, 
with  or  without  pain  in  the  bladder,  is  frequently  the  chief  symptom. 

It  is  possible  to  outline  the  pelvic  portion  of  the  thickened,  tender 


DISEASES  OF   THE    URETERS  877 

ureter  by  a  vaginal  examination.  The  fingers  introduced  to  the  antero- 
lateral wall  of  the  vagina  will  follow  the  cord  as  it  passes  to  the  vault 
of  the  vagina  and  on  to  the  side  of  the  cervix.  It  must  not  be  mistaken 
for  a  thickened  adherent  tube  or  ovary.  Through  the  rectum  the  ureter 
may  be  traced  to  a  higher  level. 

Tenderness  on  pressure  will  serve  as  a  guide  to  the  course  of  the 
ureter  through  the  abdomen. 

In  a  cystoscopic  examination  the  ureteral  prominence  is  seen  to  be 
injected  with  bloodvessels  radiating  from  the  ureteral  orifice.  Cloudy 
and  purulent  urine  may  be  seen  to  drip  from  the  orifice  into  the 
bladder. 

A  ureteral  catheter  will  serve  to  collect  the  urine  from  the  affected 
ureter,  and  this  can  be  compared  with  the  urine  from  the  other  ureter. 

Tuberculous  ureteritis  is  almost  never  a  primary  infection,  but  is 
usually  secondary  to  tuberculous  pyelonephritis. 

We  may  speak  of  an  ascending  tuberculous  infection  when  the 
ureter  is  involved  secondary  to  the  bladder;  of  a  descending  tuberculous 
infection,  when  the  kidney  is  primarily  infected.  The  infection  may 
descend  on  one  side  and  subsequently  ascend  on  the  other  side. 

The  walls  of  the  ureter  are  greatly  thickened  and  the  lumen  is 
narrowed  from  thickening  and  caseous  degeneration  of  the  mucosa. 
Healing  of  ulcerated  surfaces  may  result  in  a'  cicatricial  contraction 
and  obliteration  of  the  lumen;  the  ureter  may  be  further  obstructed 
by  a  plug  of  caseous  material.  This  obstruction  leads  to  hydroneph- 
rosis, and,  finally,  to  cystic  degeneration  of  the  kidney.  A  tuberculous 
pyonephrosis  will  almost  inevitably  result  from  such  obstruction. 

The  symptoms  are  the  same  as  found  in  ordinary  forms  of  ureteritis, 
only  they  are  more  pronounced. 

In  advanced  cases  blood  is  found  in  the  urine.  Pus  is  invariably 
present  in  the  urine,  and  in  it  tubercle  bacilli  are  occasionally  found. 
A  positive  clinical  diagnosis  can  only  be  made  by  finding  the  tubercle 
bacillus  in  the  urine  catheterized  from  the  ureters.  When  found  in 
the  presence  of  a  thickened,  tender  ureter,  the  diagnosis  of  tuberculous 
urethritis  is  established. 

The  smegma  bacillus  closely  simulates  the  tubercle  bacillus  in  its 
size,  form,  and  staining  qualities.  It  is  found  in  the  secretions  of 
the  external  genitals,  and  is  not  to  be  confounded  with  the  tubercle 
bacillus.    In  a  catheterized  specimen  no  smegma  bacilli  will  be  found. 

Inoculation  experiments  may  be  carried  out  on  guinea-pigs  and 
rabbits,  with  promising  results.  Injections  with  tuberculin  as  a 
diagnostic  measure  have  been  made,  and  with  positive  results. 

The  finding  of  tuberculosis  in  the  bladder  or  kidney,  associated  with 
an  irregularly  thickened  tender  cord,  should  establish  the  diagnosis 
of  tuberculous  ureteritis  to  a  high  degree  of  probability. 

Treatment. — During  the  acute  stage  of  ureteritis  the  treatment 
must  be  purely  expectant.  It  consists  of  rest  in  bed,  ice-bags  over 
the  affected  parts,  the  management  of  associated  lesions  in  the  kidney 
and  bladder,  and  relief  from  pain  by  analgesics,  if  demanded. 


878  DISEASES  OF  THE  URINARY  SYSTEM 

In  the  chronic  stage  of  ureteritis  the  treatment  must  be  directed 
not  alone  to  the  ureter  but  to  the  kidney  and  bladder  as  well  if  these 
organs  are  infected. 

When  there  is  not  a  complete  obstruction  to  the  passage  of  the 
urine  through  the  ureter,  as  ascertained  by  the  passage  of  a  catheter, 
much  may  be  done  to  clear  up  the  infection  by  washing  out  the 
pelvis  of  the  kidney  and  ureter  through  a  ureteral  catheter.  For 
this  purpose  a  1  to  10,000  to  1  to  40,000  solution  of  bichloride  of 
mercury  may  be  used  two  to  three  times  a  week.  In  addition  to 
this,  urotropin  in  7  grain  doses,  repeated  three  times  daily,  may  be 
administered. 

When  stricture  or  complete  occlusion  of  the  ureter  follows  the  treat- 
ment becomes  surgical.    (See  page  883.) 

Tuberculous  Ureteritis. — The  treatment  of  tuberculous  ureteritis  may 
be  tentative  or  radical,  depending  upon  the  extent  of  the  involvement 
and  the  degree  of  disturbances  created  with  particular  reference  to 
the  general  condition  of  the  patient. 

If  there  is  great  depression  surgery  cannot  be  invoked,  but  we  may 
be  guided  by  the  rule  that  the  lesion  demands  surgical  intervention 
if  the  general  condition  of  the  patient  will  permit  and  if  the  disease  is 
not  so  widespread  as  to  be  unmanageable. 

Removal  of  the  affected  kidney  and  ureter  is  the  only  possible  treat- 
ment that  will  promise  permanent  results,  but  before  resorting  to  such 
radical  measures,  it  must  be  known  with  certainty  that  the  opposite 
kidney  and  ureter  are  not  likewise  involved. 

To  remove  the  kidney  and  ureter  the  extraperitoneal  route  should 
be  chosen.  Kelly  makes  a  long  incision  in  the  loin  in  front  of  the 
quadratus  muscle,  half-way  between  the  ribs  and  ilium,  and  continues 
in  an  oblique  direction  downward  and  forward,  skirting  the  anterior 
superior  spine  within  4  cm.  (1|  inches)  of  it,  and  ending  in  the  semilunar 
line  over  the  top  of  the  broad  ligament.  He  then  divides  the  skin, 
fat,  muscles,  and  fascia  down  to  the  peritoneum,  which  he  dissects 
up  by  the  fingers.  He  locates  the  ureter  by  raising  the  colon.  If  not 
readily  seen,  he  traces  it  from  the  pelvis  of  the  kidney  downward.  The 
peritoneum  need  not  be  opened  at  any  point.  After  freeing  the  kidney 
by  ligating  its  vessels  and  detaching  the  abdominal  portion  of  the 
ureter,  he  frees  the  pelvic  portion  by  following  the  upper  portion  as 
a  guide,  while  the  fingers  lift  the  pelvic  peritoneum  from  the  vessels 
which  drop  with  the  ureter  over  the  brim.  By  pulling  it  out,  the  ureter 
is  freed  down  to  the  floor  of  the  pelvis  and  forward.  To  complete 
the  enucleation  as  far  as  the  vesical  attachment,  the  uterine  artery 
and  veins  are  tied  and  divided. 

Obstruction  of  the  Ureter. — The  ureter  is  more  frequently  obstructed 
in  women  than  in  men,  owing  to  the  pressure  exerted  upon  the  ureter 
by  swellings  of  the  uterus,  tubes,  and  ovaries. 

Causes. — ^The  following  classification  is  made  by  Kelly: 

First,  causes  acting  from  without  and  occluding  the  ureter  hy  'pressing 
upon  it,  such  as:     ^ 


DISEASES  OF  THE   URETERS  879 

1.  Ovarian  tumors. 

2.  Uterine  tumors. 

3.  Cancerous  infiltration  of  the  broad  ligaments. 

4.  Cancer  of  the  cecum. 

5.  Retroperitoneal  pelvic  sarcoma, 

6.  Aneurysm  of  the  iliac  artery. 

7.  Scar  tissue  in  the  broad  ligament. 

8.  Perineuritis. 

9.  An  omental  adhesion  to  the  pelvic  brim. 

10.  Thickened  bladder  walls. 

11.  Sarcoma  of  the  bladder. 

12.  Pedunculated  tumor  of  the  bladder. 
Second,  foreign  bodies  lodged  in  the  ureteral  canal: 

1.  Calculus. 

2.  Blood  clot. 

3.  Echinococcus  cyst. 

Third,  affections  of  the  ureteral  walls  themselves: 

1.  Ureteritis  bacillus  coli  communis. 

2.  Ureteritis  gonorrheica. 

3.  Ureteritis  tuberculosa. 

4.  Valve  formation  in  the  ureteral  wall. 

5.  Gumma  in  the  wall. 

6.  Cancer  of  the  ureter. 

7.  Psorospermial  cysts. 

The  point  of  obstruction  is  most  frequent  in  the  pelvic  portion  of 
the  ureter.  Here  the  ureter  is  often  engaged  between  the  unyielding 
bony  wall  of  the  pelvis  and  various  tumors  and  inflammatory  swellings 
within  the  pelvis.    One  or  both  ureters  may  be  involved. 

Diagnosis. — The  diagnosis  involves  not  only  the  fact  of  obstruction 
to  the  ureter,  but  the  determination  of  the  cause  of  the  obstruction, 
its  location,  the  rapidity  with  which  it  has  developed,  and  the  extent 
of  the  obstruction. 

The  clinical  manifestations  are  variable  and  unreliable.  Pain  in 
the  region  of  the  kidney  and  ureter  is  the  most  constant  symptom, 
yet  a  moderate  degree  of  obstruction  may  exist  without  causing  symp- 
toms. The  more  rapidly  the  obstruction  develops,  the  greater  are  the 
clinical  disturbances. 

Frequent  painful  urination  suggests  an  inflammatory  obstruction 
or  a  calculus.  Symptoms  are  particularly  unreliable  as  a  guide  to 
the  diagnosis  in  a  slowly  developing  obstruction.  When  the  ureter 
has  been  suddenly  plugged  with  a  calculus  or  blood-clot,  the  intensity 
and  location  of  the  pain  are  so  characteristic  as  to  frequently  serve 
for   a  diagnosis. 

In  making  a  diagnosis  of  obstruction  of  the  ureter,  all  causes  above 
enumerated  are  to  be  sought  for.  All  swellings  of  the  pelvis  are  to  be 
outlined  in  a  bimanual  examination.  When  there  is  frequent  painful 
urination  and  the  cause  of  the  disorder  cannot  be  located  in  the  ureter 
or  bladder,  it  becomes  imperative  to  explore  the  ureters  by  bougies 


880 


DISEASES  OF  THE   URINARY  SYSTEM 


and  catheter.  An  inflammatory  swelling  of  the  ureter  palpated  through 
the  vaginal  wall  suggests  a  probable  cause  for  the  obstruction,  but 
does  not  eliminate  the  possible  existence  of  other  causes. 


Fig.  607 


Diagram  of  course  of  ureter,  showing  the  usual  locations  of  ureteral  calculi. 

The  only  positive  means  of  locating  an  obstruction  in  the  ureter 
is  by  the  passage  of  a  bougie  or  catheter.  The  instrument  will  meet 
with  an  obstruction  at  a  point  below  the  pelvis  of  the  kidney,  or  after 
passing  a  given  point  with  some  resistance,  the  constricted  portion 
grasps  the  instrument  so  as  to  resist  its  withdrawal.  Occasionally  when 
passing  a  ureteral  catheter  no  special  resistance  will  be  noticed  until 


DISEASES  OF  THE   URETERS 


881 


Fig.  608 


there  appears  a  sudden  discharge  of  an  unusual  amount  of  fluid  which 
has  accumulated  behind  the  obstruction. 

Ureteral  Calculus. — Calculi  may  lodge  at  any  point  in  the  course 
of  the  ureter,  but  are  most  often  found  near  the  pelvis  of  the  kidney, 
the  floor  of  the  pelvis,  and  the  flexure  at  the  pelvic  brim.  These 
calculi  are  elongated  and  cone-shaped.    They  are  of  rare  occurrence. 

Diagnosis. — ^A.  probable  diagnosis  is 
based  upon  the  periodic  recurrence  of  a 
colicky  pain  radiating  from  the  kidney 
along  the  course  of  the  ureter.  Following 
these  attacks  of  pain  there  may  be  a  rise 
of  temperature  and  the  appearance  of 
blood  in  the  lu-ine.  The  .r-rays  will  often 
locate  the  stone  with  accuracy,  and  should 
be  used  in  all  suspected  cases. 

The  symptoms  are  the  same  as  those  of 
renal  calculi. 

The  passage  of  a  calculus  along  the 
ureter  is  suspected  when  pain,  tenderness, 
and  hematuria  have  persisted  for  several 
days  and  the  tenderness  is  found  to  descend 
along  the  course  of  the  ureter  from  time  to 
time,  and  is  finally  located  in  the  bladder. 

Occasionally  the  stone  will  act  as  a  ball- 
valve  in  plugging  the  ureteral  opening  of 
the  pelvis  of  the  kidney.  In  such  an 
event  there  will  be  a  temporary  hydro- 
nephrosis with  intermittent  discharge  of 
the  contents  through  the  ureter.  Under 
favorable  conditions  a  stone  may  be  pal- 
pated through  the  vaginal  wall,  rectum,  or 
abdominal  wall.  In  rare  instances  a  stone 
has  been  seen  through  a  cystoscope  to 
project  from  the  ureter  into  the  bladder. 

When  the  stone  lies  higher  up  in  the 
ureter,  it  is  detected  with  absolute  cer- 
tainty by  passing  a  catheter  or  sound. 
The  device  practised  by  Howard  Kelly 
of  tipping  the  catheter  or  sound  with 
wax  is  of   special  service  in  these  cases. 

Palliative  Treatment. — Pain  can  best  be  controlled  by  hypodermic 
injections  of  morphine.  Hot  fomentations  over  the  seat  of  pain  may 
aid  in  affording  relief.  If  the  pain  is  checked  the  case  may  be  treated 
expectantly  in  the  hope  that  the  stone  may  pass  into  the  bladder. 

Operative  Treatment. — The  onset  of  distention  of  the  kidney  and 
lu-eter  is  the  signal  for  immediate  operative  interference. 

Before  proceeding  with  the  operation  it  is  necessary  to  locate  the 
stone.    This  may  be  done  with  the  .r-ray  in  a  large  proportion  of  cases, 
56 


Hydroureter  and  hydronephrosis. 
The  ureter  and  pelvis  of  the  kidney 
are  distended  vrith  urine.  The  ob- 
struction was  due  to  adhesions  in  the 
pehds. 


882 


DISEASES  OF  THE  URINARY  SYSTEM 


A  more  accurate  demonstration  is  made  with  the  ureteral  catheter, 
by  which  the  exact  position  of  the  stone  is  demonstrated  at  the  point 
of  obstruction  to  the  passage  of  the  catheter. 

The  extraperitoneal  route  is  preferred  in  all  cases;  this  is  the  impera- 
tive choice  when  the  ureter  is  infected. 

When  the  stone  lies  near  the  pelvis  of  the  kidney  an  incision  is  made 
in  the  lumbar  region,  and  through  this  incision  the  upper  segment  of 
the  ureter  is  exposed  and  the  stone  palpated.  A  longitudinal  incision 
is  made  down  upon  the  stone,  taking  care  to  avoid  the  vessels  and  all 
unnecessary  injury  to  the  ureter.  The  stone  is  extracted  and  the 
incision  closed  with  interrupted  sutures  of  silk  or  linen. 

When  the  stone  lies  at  a  lower  level,  and  yet  above  the  brim  of 
the  pelvis,  the  usual  incision  for  the  appendix  may  be  made  down  to 
the  peritoneum.  The  operator  then  dissects  the  peritoneum  from  the 
abdominal  wall,  carrying  with  it  the  cecum,  and  thereby  exposing 
the  ureter  with  its  contained  stone.  The  incision  into  the  ureter,  the 
removal  of  the  stone,  and  the  closure  of  the  wound  are  made  as  in 
the  removal  of  the  stone  through  the  lumbar  incision. 

Fig.  609 


Removal  of  ureteral  calculus.     (Gellhoru.) 


Stone  located  near  the  bladder  can  best  be  reached  through  an 
incision  made  in  the  linea  semilunaris  down  to  the  peritoneum.  Then 
by  dissecting  the  peritoneum  from  the  pelvic  wall  the  stone  is  reached 
and  removed  in  the  manner  described  above. 

In  selected  cases  it  is  possible  to  remove  a  stone  from  the  lower  end 
of  the  ureter  by  an  incision  made  through  the  vaginal  wall.  Through 
this  incision  the  stone  is  extracted  and  the  wound  in  the  ureter  closed 
with  sutures.  If  there  is  any  doubt  as  to  the  permanency  of  the  closure, 
the  incision  through  the  wall  of  the  vagina  may  be  left  open  for  drainage. 


DISEASES  OF  THE   URETERS 


883 


Wiien  the  stone  presents  at  the  ureteral  opening  into  the  bladder 
it  is  possible  to  enlarge  the  opening  by  scissors  passed  through  a  urethro- 
scope and  then  to  extract  the  stone  with  forceps. 

Removal  of  Ureteral  Calculi  binder  the  Guidance  of  the  Cystoscoye. — 
Gellhorn  describes  a  method  of  removing  ureteral  calculi,  in  •^'hich  he 
distends  the  bladder  with  sterile  water,  introduces  a  cystoscope,  and 
upon  exposing  the  ureteral  orifice,  he  inserts  a  slender  alligator  forceps, 
such  as  are  used  in  removing  foreign  bodies  from  the  larynx. 

Fig.  610 


Ureteral  stricture  causing  distention  of  peh-is  and  slight  hydronephrosis,     o,  point  of  stricture. 


Stricture  of  the  Ureter. — Direct  violence  is  seldom  the  cause  of  stricture 
of  the  ureter,  because  of  its  deep-seated  position.  The  passage  of  a 
stone  may  result  in  a  stricture,  as  may  also  long-standing  inflammatory 
lesions  in  and  about  the  ureter,     k  few  are  congenital  in  origin. 

The  urine  may  be  voided  frequently,  and  with  pain.  There  are 
no  findings  in  the  urine  to  suggest  the  diagnosis.    Tenderness  in  the 


884 


DISEASES  OF   THE   URINARY  SYSTEM 


flanks  is  a  common  complaint.  There  may  also  be  pain  in  the  bladder. 
When  the  stricture  is  within  or  below  the  broad  ligament  it  may  some- 
times be  palpated  through  the  vagina  as  a  firm  cord. 

Hydroureter  and  Hydronephrosis  develop  when  the  passage  of  the 
urine  is  obstructed.  Pyoureter  and  pyonephrosis  may  develop  secondary 
to  an  obstruction  in  the  ureter,  and  are  dependent  upon  a  pyogenic 
infection.  These  conditions  are  diagnosticated  by  the  passage  of  a 
catheter  beyond  the  point  of  obstruction  and  the  emptying  of  the 
accumulated  fluid.  Abdominal  palpation  may  detect  a  c}'stic  swelling. 
Continuous  pain  or  intermittent  colic  in  the  region  of  the  kidney  and 
ureter  are  highly  suggestive  of  the  condition,  though  no  positive  diag- 
nosis can  be  made  without  an  exploratory  puncture  through  an  incision 
in  the  back  or  catheterization  of  the  ureter. 


Fig.  611 


The  mode  of  applying  the  sutures  after  division  of  a  ureteral  stricture  of  a  valve. 


Treatment. — The  stricture  may  be  dilated  when  resident  in  the 
pelvis,  provided  it  is  possible  to  pass  a  bougie  through  the  constriction, 
and  provided  the  stricture  is  benign  and  yielding.  Great  perse^•e^ance 
may  be  demanded  in  making  repeated  attempts  to  pass  the  bougie 
and  in  progressing  from  the  smaller  to  the  larger  sizes  of  bougies. 

If  an  infected  ureter  lies  above  the  point  of  constriction  a  cure  may 
be  eftected  by  irrigating  the  pelvis  of  the  kidney  and  ureter  with  a 
bichloride  of  mercury  solution,  1  to  100,000  to  1  to  40,000,  and  repeating 


DISEASES  OF  THE  URETERS  885 

the  process  daily  until  the  urine  is  free  of  pus.  Such  fortunate  results, 
however,  are  seldom  obtained  by  so  conservative  a  method. 

When  atrophic  changes  have  taken  place  in  the  kidney  no  good  can 
come  from  the  painstaking  task  of  dilating  the  ureter. 

Traumatic  strictures  of  the  ureter  are  of  rare  occurrence.  The 
location  most  favorable  for  treatment  of  these  strictures  is  at  either 
end  of  the  ureter.  They  may  be  divided  longitudinally  and  sutured 
in  the  opposite  direction,  so  that  the  opening  through  the  ureter 
is  greatly  enlarged.  This  would  not  be  a  difficult  matter  at  the  upper 
end  of  the  ureter. 


CHAPTER  XXXIII 


POSTOPERATIVE  TREATMENT 


Responsibility  for  Complications 

Stimulation 

Position  of  Patient 

Relief  from  Pain 

Nourishment 


Evacuation  of  Bladder 
Care  of  the  Bowels 
Application  of  Ice  to  Abdomen 
Duration  of  Convalescence 
Early  Rising 


RESPONSIBILITY  FOR  COMPLICATIONS  ARISING  AFTER 
OPERATIONS 


It  may  be  said,  without  fear  of  contradiction,  that  the  comphcations 
arising  after  operation  are  largely  preventable,  and  that  the  respon- 
sibility for  such  complications  rests  in  large  measure  with  the  attending 
surgeon. 

Shock  follows  an  operation,  and  it  is  observed  that  an  operation  of 
election  has  been  performed  in  the  presence  of  grave  anemia  or  of  an 
incompetent  heart;  pneumonia  develops  after  an  operation,  and  it  is 
ascertained  that  at  the  time  of  the  operation  the  patient  was  suffering 
from  a  bronchitis  or  that  there  was  an  unnecessary  exposure  to  draught 
in  the  operating  room  or  after  the  operation;  there  is  profound  shock 
following  the  operation,  and  the  operator  is  known  to  have  unnecessarily 
exposed  and  handled  the  viscera,  or  the  anesthetic  was  given  in  too 
large  quantities.  Localized  foci  of  infection  or  general  peritonitis 
result  from  lax  methods  in  technic  or  untimely  surgical  intervention 
in  cases  of  acute  pelvic  infection.  These  and  many  other  examples 
may  be  cited  in  support  of  the  statement  that  the  surgeon  is  not  infre- 
quently responsible  for  the  complications  arising  after  operation. 

There  is  a  certain  degree  of  discomfort  associated  with  every  con- 
valescence from  a  surgical  operation.  Experience  is  required  to  alleviate 
these  discomfitures,  and  when  they  become  exaggerated  the  respon- 
sibilities of  the  surgeon  may  be  made  even  greater  than  in  the  per- 
formance of  an  operation.  Indeed,  it  may  be  contended  that  the  services 
of  a  sJcilled  and  experienced  surgeon  are  as  indispensable  in  the  after- 
treatment  as  in  the  operation,  and  hence  it  follows  that  the  surgeon  who 
relegates  the  after-treatment  to  assistants  of  limited  experience  falls  short 
of  fulfilling  his  obligations  to  his  patients. 

As  soon  as  an  operation  is  complete  and  the  stitches  removed,  the 
gynecologist  frequently  regards  his  services  at  an  end.  He  volunteers 
some  words  of  advice  as  to  the  amount  and  character  of  the  exercise, 
the  food  and  rest  his  patient  should  take,  his  assistant  records  the 


COMPLICATIONS  ARISING  AFTER  OPERATIONS 


887 


patient  as  recovered  on  the  history  sheet,  and  the  transaction  is  closed, 
unless  again  opened  up  by  further  appeals  from  the  patient.  Is  this 
the  proper  attitude  for  the  surgeon  to  assume?  Decidedly  not.  With 
added  experience  the  author  attaches  more  and  more  importance  to 
postoperative  treatment.  He  is  impressed  with  the  necessity  of  admin- 
istering postoperative,  general,  and  local  treatments,  which  tend  to 
restore  the  integrity  of  the  organs,  and  of  regulating  and  strengthening 
the  general  system,  so  that  not  one  but  all  of  the  organs  and  functions 
of  the  body  are  brought  into  general  harmony.  The  gynecologist  who 
is  the  most  successful  and  reliable  is  the  one  who  places  a  just  estimate 
on  medicine  and  surgery  and  employs  them  without  predilection  and 
prejudice. 

Fig.  612 


Abdominal  pad  applied  after  laparotomy. 


After  operation  we  frequently  find  our  patient  nervous;  she  is  neur- 
asthenic, melancholic,  or  hysterical.  Shall  we  dismiss  such  a  patient 
and  turn  her  over  to  the  harassing  influences  of  her  friends  and  to  the 
nerve-racking  cares  of  the  household?  To  do  so  is  to  commit  her  to 
permanent  invalidism.  She  needs  sympathy,  encouragement,  and 
education,  in  order  that  her  disordered  mentality  shall  be  restored 
to  its  proper  balance.  She  is  frequently  poorly  nourished  and  her 
muscular  development  is  weak;  it  is  not  sufficient  to  give  her  general 
instructions,  but  rather  should  she  be  under  constant  direction  in  her 
diet  and  exercise.  The  bowels  and  kidneys  fail  to  perform  their  func- 
tions, and  must  be  regulated  not  alone  through  the  three  or  four  weeks 
of  convalescence,  but  for  all  time.  We  have  curetted  a  subinvoluted 
or  metritic  uterus,  but  it  remains  enlarged  and  congested  if  not  followed 


POSTOPERA  TI T  'E  TREA  TMENT 


persistently  by  vaginal  douches  and  tampons.  We  have  broken  up 
numerous  adhesions  which  may  re-form  if  the  douches  and  tampons 
are  neglected.  We  have  replaced  the  uterus  by  ventrosuspension  or 
shortening  of  ligaments,  and  without  the  wearing  of  a  pessary,  for 
two  or  more  months,  the  chances  of  recurrence  are  increased.  These 
and  many  other  instances  may  be  cited  to  emphasize  the  importance 
of  postoperative  treatment. 

A  consideration  of  the  postoperative  management  of  cases  will  be 
of  interest. 

Fig.  613 


Elevation  of  the  head  of  the  bed. 


1.  Stimulation. — Stimulation  during  and  after  the  operation  may 
become  imperative.  The  author  usually  orders  a  rectal  injection  of  a 
pint  of  salt  solution  and  two  ounces  of  whisky  immediately  after  the 
patient  is  returned  to  her  bed  after  all  major  operations,  when  there  is 
the  least  depression.  When  the  pulse  is  weak  and  rapid  these  injections 
may  be  repeated  every  four  to  six  hours,  and  if  deemed  necessary  they 
may  be  substituted  or  reenforced  by  subcutaneous  injections  of  normal 
salt  solution,  given  preferably  in  the  breasts.  Hypodermic  injections 
of  strychnine  sulphate,  grain  -g^  to  ^o"?  '^^Y  be  given  at  intervals  of 
two  to  six  hours.  Judgment  must  be  exercised  in  the  employment 
of  these  stimulants;  one's  anxietv  mav  lead  him  into  the  error  of  over- 


COMPLICATIONS  ARISING  AFTER  OPERATIONS  889 

stimulation.     When  there  is  nervousness,  strychnine  should  be  given 
sparingly. 

2.  Position  of  Patient. — The  position  the  patient  is  made  to  assume 
in  bed  varies  with  the  conditions  found  after  operation.  Raising  the 
foot  of  the  bed  twelve  to  twenty  inches  will  greatly  favor  a  weakened 
heart  action.  On  the  contrary  such  a  position  has  serious  objections 
in  that  the  diaphragm  is  encroached  upon  and  its  excursions  embarrassed 
by  the  abdominal  contents.  Bearing  this  in  mind  the  author  has  fre- 
quently raised  the  head  and  trunk  on  pillows  to  an  angle  of  45  degrees. 
The  effect  is  to  cause  the  abdominal  contents  to  fall  away  from  the 
diaphragm,  thereby  favoring  deep  respirations,  and  this  in  turn  favors 


Fig.  614 


Elevation  of  the  foot  of  the  bed. 

the  heart  action.  Furthermore,  it  is  observed  that  this  position  materi- 
ally lessens  the  distressing  nausea  and  vomiting  and  favors  the  expulsion 
of  gas  and  the  evacuation  of  the  bladder.  When  the  pelvis  has  been 
contaminated,  as  in  the  rupture  of  a  pus-tube,  this  position  will,  in  a 
measure,  prevent  the  spread  of  the  infection  to  the  abdomen.  The 
question  is  often  asked,  "How  soon  after  the  operation  can  the  patient 
turn  on  her  side?"  It  is  a  source  of  relief  for  the  patient  to  turn  from 
the  back  to  the  side,  and  there  is  seldom  any  objection  to  permitting 
her  to  do  so  from  the  onset,  and  to  remain  lying  on  the  side  with  the 
back  supported  by  pillows.  u   i  •  j 

The  nurse  or  doctor  must  be  in  constant  attendance  at  the  bedside 
until  the  patient  has  regained  consciousness.     Care  must  be  taken 


890 


POSTOPERATIVE  TREATMENT 


that  the  patient  does  not  burn  herself  with  hot-water  bottles  when 
unconsciously  moving  about  in  the  bed,  and  that  the  throat  be  kept 
free  of  mucus  and  vomitus. 

3.  Relief  from  Pain. — Relief  from  pain  often  becomes  imperative. 
Some  operators  proscribe  all  opiates  after  operation,  on  the  theory 
that  they  lock  up  the  secretions.  It  is  my  opinion  that  this  objection 
is  more  than  counterbalanced  by  the  relief  from  pain,  affording  the 
patient  much  needed  rest  after  the  strain  of  the  operation.  The  author 
is  in  the  habit  of  giving  ^  grain  of  codeine  or  y^  grain  of  heroin  hypo- 
dermically,  and  repeating  it  in  two  or  four  hours  if  necessar}^  Occa- 
sionally the  pain  is  so  intense  that  nothing  short  of  morphine  will  bring 
relief. 

Fig.  615 


Fowler  position. 


Much  of  the  pain  in  the  abdomen  is  caused  by  gaseous  distention 
of  the  bowel,  which  is  best  relieved  by  the  rectal  tube  passed  high  into 
the  bowel  and  by  enemata.  An  ounce  of  powdered  alum  dissolved  in 
a  pint  of  warm  water  injected  into  the  bowel  will  often  give  quick 
relief;  or  equal  parts  of  warm  milk  and  molasses  will  be  found  effective. 
The  author  has  had  gratifying  results  by  giving  a  hypodermic  of  eserine, 
grain  ^V'  twenty  minutes  before  giving  the  enema.  The  eserine  mate- 
rially aids  in  the  expulsion  of  gas.  As  stated  above,  gas  pains  will  be 
materially  lessened  by  raising  the  patient  in  a  semisitting  posture. 
Hot  fomentations  and  turpentine  stupes  are  effective  in  relieving  gas 
pains.  Before  applying  them  the  dressing  over  the  wound  should  be 
protected  by  a  covering  of  oiled  silk. 


COMPLICATIONS  ARISING  AFTER  OPERATIONS  891 

4.  Nourishment. — The  nourishment  in  the  postoperative  stage  is 
a  subject  which  cannot  be  disposed  of  by  formulating  definite  rules. 
No  nourishment  can  be  retained  in  the  stomach,  as  a  rule,  in  the  twenty- 
four  hours  immediately  following  operation.  Hot  water  may  be  sipped 
at  intervals,  and  within  a  few  hours  cool  water  may  be  given  ad  libitum, 
provided  it  is  retained.  Large  quantities  of  cold  water  seem  to  engender 
gas  pains,  and  should  be  avoided. 

Champagne  in  cracked  ice  is  often  most  gratifying  at  this  time,  or 
a  less  expensive  substitute,  seltzer  water  or  beer,  may  be  given.  Broth, 
soups,  and  milk  can  usually  be  borne  at  the  end  of  twenty-four  hours, 
and  a  light  but  nutritious  diet  can  usually  be  begun  on  the  third  day. 

Fig.  616 


^ 


Catheterizing  the  bladder.     Nurse  holding  the  labia  apart  while  passing  the  catheter. 

If  milk  is  not  well  borne  it  is  well  to  add  seltzer  water,  lime  water,  or 
Apollinaris.  If  nausea  persists  so  that  no  food  can  be  retained  after  the 
first  twenty-four  hours  a  nutrient  enema  should  be  given  to  maintam 
the  strength.  This  enema  may  consist  of  60  c.c.  of  milk,  30  c.c.  of 
cream,  the  yolk  of  two  eggs,  and  two  drams  of  whisky  or  brandy. 
(See  Chapter  XIII.)  Before  resorting  to  nutrient  enemata  the  stomach 
should  be  washed  out  and  the  stomach  feeding  again  tried. 

5.  Emptying  of  the  Bladder.— After  operating  upon  the  vulva  and 
vagina  there  is  often  much  difficulty  experienced  in  voiding  the  urine. 


892 


POSTOPERATIVE  TREATMENT 


The  danger  of  infecting  the  urethra  and  bladder  by  means  of  the  catheter 
is  great,  and  hence  the  patient  must  be  encouraged  to  void  the  urine. 
A  satisfactory  procedure  has  been  suggested  by  Dr.  J.  B.  INIurphy.  It 
consists  in  injecting  into  the  anterior  segment  of  the  urethra  two  drops 
of  spirits  of  camphor.  A  medicine  dropper  may  be  employed  for  this 
purpose.  The  effect  is  to  produce  a  peculiar  sensation,  which  impels 
the  patient  to  urinate  within  a  few  minutes.  There  is  little  or  no 
discomfort  unless  the  injection  comes  in  contact  with  the  vulvar 
surface,  when  it  will  cause  smarting  and  burning.  The  employment 
of  this  method  has  obviated  the  necessity  of  using  the  catheter  in 
nearlv  all  cases. 


Fig.  617 


Propping  patient  on  side  with  pillows. 


When  necessary  to  use  the  catheter  the  utmost  care  must  be  exercised. 
The  glass  catheter  is  preferred  to  rubber;  it  must  be  boiled  before  using, 
or  boiled  and  kept  in  a  5  per  cent,  carbolic  acid  solution  until  used,  and 
is  rinsed  in  sterile  water  before  inserting  into  the  urethra.  In, unskilled 
hands  the  rubber  catheter  is  the  safer,  and  this  can  best  be  sterilized 
by  boihng  before  using. 

Catheterization  is  a  surgical  procedure  and  must  he  performed  in  com- 
pliance with  the  principles  of  surgical  cleanliness.  The  catheter  should 
never  be  passed  under  a  sheet,  but  a  good  light  should  be  provided  and 


COMPLICATIOXS  ARISIXG  AFTER  OPERATIONS  893 

the  vulva  exposed  so  as  to  bring  the  urethral  orifice  into  view  upon 
separating  the  labia  with  the  forefinger  and  thumb  of  the  left  hand. 
A  boric  acid  solution  may  be  used  to  sponge  oft'  the  urethral  orifice 
and  the  neighboring  structures.  Then  the  catheter  is  inserted,  taking 
care  not  to  force  it,  but  rather  to  let  it  find  its  way  into  the  bladder, 
merely  directing  its  course.  On  removing  the  catheter  place  the  end 
of  the  index-finger  over  the  outlet  of  the  catheter  so  that  its  contents 
will  not  escape  upon  the  vulva.  Great  care  should  be  taken  in  passing 
the  catheter  to  avoid  touching  the  catheter  to  the  labia,  for  in  so  doing 
infection  may  be  carried  to  the  urethra.  A  large  proportion  of  cases 
of  cystitis  are  caused  in  this  manner. 

Fig.  618 


Elevating  the  knee  by  pillows  to  relax  the  abdominal  wall. 

6.  Care  of  the  Bowels  after  Operation. — Unless  it  is  imperative 
that  the  bowels  should  be  locked  for  a  given  time,  catharsis  may  be 
inaugurated  twenty-four  hours  after  operation.  The  author's  custom 
is  not  to  disturb  the  bowels  until  the  morning  of  the  fourth  day  of  the 
operation.  In  so  doing  a  residue  accumulates  in  the  bowel,  so  that  a 
cathartic  or  enema  calls  forth  a  ready  response  from  the  bowel,  and 
without  the  griping  pains  so  commonly  experienced  from  early  catharsis. 

The  author  usually  orders  a  grain  each  of  calomel  and  soda,  to  be 
repeated  in  two  hours.  Four  hours  later  a  half -ounce  of  Epsom  salts 
is  given,  and  if  this  does  not  give  the  desired  results  an  enema  is  given, 
consisting  of  Epsom  salts  2  ounces,  glycerin  2  ounces,  and  water  4 
ounces.  Thereafter  a  half-ounce  of  compound  glyc^Trhiza  powder  may 
be  given  from  day  to  day.  Enemata  may  be  injected  as  required.  The 
author  is  prejudiced  against  the  rule  of  giving  cathartics  in  the 
evening,  because  the  sleep  is  unnecessarily  disturbed. 

7.  Ice  Applications  to  the  Abdomen.— Simpson,  of  Pittsburg,  recom- 
mends the  application  of  ice-bags  to  the  abdomen,  both  asa  prophylactic 
and  as  a  curative  measure  in  pehdc  and  general  peritonitis.  _  He  bases 
his  opinion  on  extensive  clinical  and  experimental  observations.  One 
to  five  ice-bags  are  placed  close  to  the  surface  of  the  abdomen. 
He   extols   the  practice  for   the  rehef  of  pain  and  the  prevention  of 


894 


POSTOPERATIVE  TREATMENT 


peritonitis,  and  believes  it  to  be  a  life-saving  agent  in  not  a  few  of  the 
grave  cases  of  general  and  localized  peritonitis.  He  does  not,  however, 
recommend  it  to  the  exclusion  of  other  well-recognized  medical  and 
surgical   measures. 

8.  Duration  of  Convalescence. — The  duration  of  the  convalescence 
is  naturally  a  variable  quantity.  For  an  ordinary  curettage  and  repair 
of  the  cervix,  five  to  seven  days  in  bed  will  usually  suffice.  After  peri- 
neorrhaphy the  patient  should  be  confined  to  her  bed  twelve  to  sixteen 
days.  Following  abdominal  sections  the  average  time  in  bed  is  ten  to 
twelve  days.  If  abdominal  drainage  has  been  established,  if  infection 
of  the  stitches  occurs,  if  the  general  condition  does  not  permit,  this 
time  must  be  extended  for  days  and  possibly  for  several  weeks. 


Fig.  619 


Combination  abdominal  binder  and  vulvar  dressing  worn  alter  operation. 

For  years  the  author  followed  the  above  rules  in  permitting  his 
patients  to  sit  up  and  walk  about  after  operations,  but  of  late  years 
he  has  encouraged  early  rising  in  a  large  proportion  of  his  cases.  For 
the  ordinary  abdominal  operations  he  does  not  confine  his  patients 
in  bed  for  more  than  three  to  five  days.  On  the  third,  fourth,  or  fifth 
day  they  are  allowed  to  sit  in  an  easy  chair,  with  legs  extended 
on  a  stool.  The  first  day  they  are  permitted  to  sit  up  perhaps  a  half- 
hour,  the  second  day  one  or  two  hours,  and  from  then  on  ;they  are 
generally  able  to  sit  up  and  walk  about  at  liberty. 

The  advantages  of  early  rising  after  operation  are: 

1.  Encouragement  to  the  patient. 

2.  Better  control  over  the  bladder,  bowels,  and  stomach. 

3.  Avoidance  of  the  weakening  influences  of  the  supine  position. 


COMPLICATIONS  ARISING  AFTER  OPERATIONS  895 

4.  A  more  speedy  restoration  to  health.  Each  case  is  a  law  unto 
itself  in  this  regard,  but  as  a  general  proposition  the  author  is  in  favor 
of  early  rising  after  operation. 

It  must  be  borne  in  mind  that  convalescence  does  not  end  with 
the  removal  of  the.  stitches  and  the  relief  from  pain  and  discomfort; 
time  must  be  allowed  for  restoring  the  general  strength  and  building 
up  the  nervous  system.  This  may  require  many  weeks  and  months, 
during  which  time  the  patient  must  be  judiciously  guided  in  her  manner 

Fis.  620 


Changing  draw  sheet  under  patient. 

of  living,  wdth  particular  regard  to  diet,  exercise,  baths,  and  rest.  Daily 
walks  and  drives  are  of  special  value,  and  to  this  end  a  climate  should 
be  sought  in  which  daily  exercise  can  be  taken  in  the  open  air,  and 
where  the  environment  is  agreeable  and  entertaining. 

There  should  be  no  social  or  domestic  cares  to  cause  fatigue  or  anxiety. 
Food  should  be  selected  in  view  of  obtaining  the  maximum  amount 
of  nourishment.  When  the  blood  is  low,  tonics,  such  as  iron,  strychnine, 
and  arsenic,  may  be  given  with  beneficial  results. 


896 


POSTOPERA  TI VE  TREA  TMENT 


Abdominal  Supporter. — It  is  well  to  provide  a  suitable  abdominal 
support  to  be  worn  after  all  abdominal  operations.  This  is  particularly 
true  of  cases  in  which  there  is  great  relaxation  of  the  abdominal  walls, 
with  general  visceroptosis;  also  of  cases  with  heavy  abdominal  walls, 
and  where  the  scar  is  imperfect  as  the  result  of  drainage.  These  supports 
should  be  worn  for  several  months,  at  the  end  of  which  time  a  straight- 
front  corset  may  be  substituted.  In  selecting  a  support  for  the  abdomen 
certain  qualifications  are  essential.  The  support  should  be  comfortable 
to  the  patient,  and  hence  should  be  made  of  light  material  that  will 


Fig.  621 


Abdominal  supporter. 


readily  absorb  moisture,  and  with  as  little  stiffening  as  will  permit  of 
a  perfect  adjustment  to  the  body.  It  should  be  held  in  place  by  side 
straps  that  will  not  constrict  the  limbs.  It  should  fit  snugly  about  the 
hips  and  loosely  about  the  waist  line,  thus  giving  firm  support  and  at 
the  same  time  elevating  the  abdomen.  It  should  be  easily  adjusted  to 
the  body.  The  author  finds  that  the  Storm  binder  fills  all  these 
requirements  except  the  last.    It  is  not  easy  of  adjustment. 

Fig.  621  illustrates  a  binder  that  is  easily  adjusted,  and  provides  good 
support  without  discomfort. 


CHAPTER  XXXIV 
COMPLICATIONS  FOLLOWING  OPERATIONS 


Surgical  Shock 

Pulmonary  Embolism 

Ileus 

Pneumonia 

Acute  Bronchitis 

Postoperative  Pleurisy 

Gangrene  of  the  Lungs 

Abscess  of  the  Lungs 

Pulmonary  Edema 

Local  and  Gener.il  Infections 

Peritonitis 

Fermentation  Fever 

Septic  Intoxication 

Septicemia 

Pyemia 
Breaking  of  Stitches 
Postoperative  Hernia 
Postoperative  Hematemesis 
Retention    and     Suppression 

Urine 
Postoperative  Neuroses 

Hysteria 

Neurasthenia 

Insanity 
Tympanites 
Phlebitis 


OF 


Acute  Dilatation  of  the  Stomach 

Vomiting 

Postoperative  Cystitis 

Acute  Nephritis 

Traumatic  Fistul^e 

Ureteral  Fistulse 

Vesical  Fistula 

Rectal  Fistulae 
Pressure  Paralysis 
Burns 

Emphysema  of  the  Abdominal  Walls 
Poisoning  by  Drugs 
Infectious    and    Contagious    Dis- 
eases 
Diarrhea 
Bed-sores 
Acid  Intoxication, 
Ophthalmia 
Late    Chloroform   and   Ether 

Poisoning 
Irregularities  of  the  Pulse 
ExcEssR'E  Pain 

Variations  in  Body  Temperature 
Secondary  Hemorrhage 
Foreign  Bodies  Left  in  the  Abdom- 
inal Cavity  after  Operation 


Surgical  Shock. — Surgical  shock  is  a  term  often  employed  indiffer- 
ently and  is  intended  to  indicate  an  extreme  depression  of  the  ^dtal 
forces  as  the  result  of  an  impression  made  upon  the  nerve  centres. 

Reed  defines  shock  as  "an  inhibition,  more  or  less  profound,  of 
practically  all  the  vital  functions,  due  to  defective  vasomotor  control, 
and  characterized  by  diminished  cardiac  force,'  lessened  arterial  tension, 
embarrassed  respiration,  muscular  relaxation,  more  or  less  complete 
arrest  of  glandular  activity  and  mental  lethargy,  varying  in  the  later 
stages  into  delirium." 

Causes. — Shock  may  occur  in  the  absence  of  an  assignable  cause 
even  in  the  light  of  a  postmortem  examination.  The  known  causes  are 
as  follows: 

(a)  Excessive  loss  of  blood,  or  a  moderate  loss  of  blood  in  individuals 
who  are  anemic.  Hence  the  importance  of  examinations  of  the  blood 
as  a  precautionary  measure  prior  to  all  major  operations. 

(6)  Prolonged  anesthesia  is  also  a  relative  quantity  in  its  effects  upon 
the  patient,  depending  not  only  upon  the  manner  of  its  administration 
but  upon  the  condition  of  the  heart  and  blood  of  the  patient. 
57 


898  COMPLICATIONS  FOLLOWING  OPERATIONS 

(c)  General  debility,  the  result  of  M^asting  diseases,  such  as  carcinoma, 
tuberculosis,  and  grave  digestive  disorders,  which  predispose  to  great 
depression  as  the  result  of  operations  under  anesthesia.  The  condition 
of  the  heart,  blood,  blood  pressure,  and  general  nourishment  are,  as 
a  rule,  reliable  indications  of  the  general  resistance  of  the  individual. 
When  the  general  resistance  of  the  body  is  low,  it  is  advisable  to  delay 
an  operation  of  election  until  strength  is  restored  through  the  judicious 
employment  of  rest,  diet,  and  tonics.  The  all  too  prevalent  disposition 
on  the  part  of  surgeons  to  operate  upon  their  cases  without  due  regard 
to  such  preliminary  measures  is  to  be  deplored. 

(d)  Prolonged  exyosure  of  the  abdominal  viscera  to  the  air  and  to  handling 
by  the  surgeon  and  his  assistants  is  not  infrequently  responsible  for 
shock.  All  this  can  be  largely  prevented  by  keeping  the  intestines  w^ell 
covered  with  sterile  gauze  pads  wrung  out  in  hot  sterile  normal  saline 
solution.  However  prolonged  the  operation  may  be,  and  whatever 
the  manipulations  required,  there  is  no  justification  for  the  prolonged 
exposure  of  coils  of  bowel.  The  author  is  impressed  with  the  importance 
of  this  precaution,  and  feels  that  it  cannot  be  too  strongly  emphasized. 
Furthermore,  there  are  many  intestinal  adhesions  which  should  not 
be  disturbed,  not  alone  because  of  the  attending  shock,  but  still  more 
because  of  the  possible  reformation  of  adhesions  which  might  leave  the 
patient  in  a  worse  condition, 

(e)  Shock  is  doubtlessly  contributed  to  by  fear  and  apprehension 
on  the  part  of  the  patient.  It  is  the  author's  belief  that  patients  who 
go  on  the  operating  table  with  fear  and  trembling  are  more  liable  to 
shock.  He  is  not  certain  as  to  just  how  much  importance  should  be 
attached  to  this  factor,  but  it  is  worthy  of  consideration.  The  surgeon 
who  keenly  appreciates  the  influence  of  these  factors  in  the  production 
of  shock,  and  does  all  in  his  power  to  rigidly  enforce  the  rules  above 
laid  down,  will  obtain  the  best  results. 

The  subject  of  surgical  shock  should  not  be  disposed  of  without 
reference  to  the  valuable  experiments  of  Dr.  George  W.  Crile,  who 
formulated  the  following  factors  contributing  to  shock: 

1.  Exposure  of  the  abdominal  viscera  to  the  atmosphere,  the  pro- 
foundness of  the  shock  varying  inversely  to  the  temperature  of  the 
air. 

2.  Manipulations  of  the  peritoneum  and  underlying  organs,  the 
intensity  of  the  shock  increasing  as  the  manipulations  progress  from 
the  pelvis  to  the  diaphragm. 

3.  Disturbance  of  the  local  vasomotor  splanchnic  areas. 

4.  Pressure  upon  important  splanchnic  veins,  especially  upon  the 
vena  cava. 

5.  Hemorrhage  to  a  degree  sufficient  to  lessen  circulatory  tension. 

6.  Earl}^  and  late  periods  of  life  are  most  susceptible  to  shock. 
Pathology. — No  anatomical  changes  incident  to  shock  have  been 

observed;  so  far  as  known  surgical  shock  only  produces  functional 
disorders  referred  to  the  sympathetic  nerve  centres.  It  is  to  be  looked 
upon  in  the  light  of  our  present  knowledge  as  essentially  a  neuroparalysis 


SURGICAL  SHOCK  '  899 

due  to  exhaustion  or  irritation  from  causes  above  named.      Crile  has 
demonstrated  certain  anatomical  changes  to  the  cerebral  cells. 

Diagnosis. — The  onset  of  surgical  shock  is  sudden  and  is  characterized 
by  signs  of  general  depression.  The  pulse  becomes  increasingly  rapid, 
weak,  and  often  irregular  in  force  and  frequency.  This  together  with 
the  evident  pallor  are  the  most  reliable  signs  of  impending  shock.  The 
pallid  surface  of  the  body  is  bathed  in  cold  perspiration;  the  pupils 
dilate  widely  and  fail  to  respond  to  the  corneal  reflex;  the  lips  are 
bloodless;  the  finger  nails  are  cyanotic;  the  eyelids  drooping;  the  respira- 
tions shallow  and  largely  abdominal;  the  temperature  falls  a  degree 
or  more  below  normal;  the  secretions  are  checked;  response  to  stimu- 
lation is  slow  or  wholly  wanting.  If  there  is  a  reaction  from  this 
state  of  depression  all  the  vital  forces  are  gradually  restored,  though 
with  no  regularity  as  to  time  and  order  of  precedence.  The  color  of  the 
skin  improves;  the  body  warmth  is  slowly  restored;  the  pulse  increases 
in  volume,  becoming  less  and  less  rapid  and  irregular;  the  respirations 
deepen  and  are  less  rapid;  the  pupils  contract  and  react  to  the  corneal 
touch;  general  muscular  control  is  restored,  and  the  facial  expression 
becomes  more  natural,  indicating  the  return  of  consciousness. 

The  stage  of  profound  depression  continues  a  variable  time,  and 
results  in  death  or  gradual  restoration.  Delirium  may  follow  upon 
complete  mental  and  physical  depression;  the  skin  becomes  dry  and 
warm;  the  face  flushes;  the  temperature  becomes  elevated;  the  pulse 
increases  in  volume;  the  patient  tosses  restlessly  upon  the  bed  and  com- 
plains of  thirst.  The  delirium  may  be  violent  or  low  and  muttering, 
and  is  followed  by  a  gradual  restoration  of  consciousness  or  by  collapse 
and  death. 

There  is  much  said  of  delayed  shock,  the  result  of  secondary  hemor- 
rhage or  of  toxins  elaborated  by  the  secreting  organs  through  the 
influence  of  the  anesthetic.  Such  a  condition  is  serious  and  demands 
immediate  investigation  into  the  contributing  factors. 

The  recognition  of  the  foregoing  clinical  signs  establishes  the  diag- 
nosis, but  there  are  certain  conditions  which  closely  simulate  shock, 
and  these  are  to  be  duly  considered. 

Hemorrhage. — The  depression  due  to  loss  of  blood  is  to  be  distin- 
guished from  that  due  to  neuroparalysis  in  order  that  restorative 
measures  may  be  effectually  administered. 

Many  of  the  symptoms  of  hemorrhage  are  identical  to  those  of  shock. 
The  increasing  weakness,  pallor,  restlessness,  and  lowered  temperature, 
in  the  presence  of  a  possible  cause  for  hemorrhage,  suggest  a  careful 
search  for  a  possible  bleeding  vessel.  The  lowered  arterial  tension  is 
suggestive  to  the  experienced  observer. 

Emboli. — Shock  may  be  closely  simulated  by  emboli  of  air,  fat,  or 
blood-clots.  Primary  respiratory  failure  and  pain  in  the  chest  are  the 
distinguishing  features  of  pulmonary  embolism. 

CJiloroform  Asphyxia. — While  chloroform  asphyxia  is  often  confused 
with  shock,  it  is  distinguished  by  the  sudden  onset  and  the  quick  response 
to  the  usual  means  employed  in  resuscitation;  this  is  in  contrast  vrith 


900  COMPLICATIONS  FOLLOWING  OPERATIONS 

the  more  gradual  development  of  the  signs  of  depression  and  the 
slower  response  to  restorative  measures  which  characterize  surgical 
shock. 

Acute  septic  infection  is  not  infrequently  regarded  as  delayed  shock. 
Here  the  signs  of  depression  develop  more  slowly  than  in  shock,  the 
temperature  rises,  and  the  pulse-rate  is  rapid  in  proportion  to  the 
temperature.  Leucocytosis,  together  with  local  manifestations  of 
infection,  should  in  most  cases  determine  the  diagnosis. 

Prognosis. — The  prognosis  is  largely  determined  by  the  manner  of 
response  to  stimulation ;  the  longer  the  reaction  is  postponed  the  graver 
the  prognosis.  Howard  Kelly  says  that  few  patients  recover  when  the 
temperature  falls  to  96°  F.  A  pulse  increasing  in  rapidity  and  develop- 
ing delirium  are  signs  of  impending  dissolution. 

Treatment. — By  far  the  most  important  consideration  is  the  prevention 
of  shock,  this  being  largely  under  the  control  of  the  operator.  The 
surgeon  who  gives  the  greatest  consideration  to  the  physical  conditions 
of  the  patient  prior  to  the  operation,  who  discriminates  wisely  in  his 
choice  of  anesthetics  and  anesthetizer,  who  operates  with  caution 
and  with  no  undue  loss  of  time,  who  avoids  unnecessary  exposure  of 
the  abdominal  viscera  and  of  the  surface  of  the  body,  and  who  loses 
little  blood  in  operations,  will  have  a  minimum  of  shock  in  his  surgical 
experience. 

Too  much  emphasis  cannot  be  placed  upon  the  preparation  of  the 
patient  for  operation.  The  general  body  strength  should  be  increased 
by  the  judicious  employment  of  rest,  exercise,  diet,  and  tonics. 

When  the  blood  is  below  40  per  cent,  of  hemoglobin  and  2,500,000 
red  corpuscles,  no  major  operation  of  convenience  should  be  attempted 
until  the  blood  has  been  brought  to  a  safe  standard,  which  would 
ordinarily  mean  an  increase  to  at  least  75  per  cent,  of  hemoglobin  and 
4,000,000  red  cells. 

Bleeding  from  the  uterus  may  be  temporarily  controlled  by  enforcing 
rest  in  bed,  by  the  administration  of  ergot,  and  by  a  preliminary 
curettage  or  the  application  of  the  cautery  to  cancerous  areas.  In 
addition  to  these  measures  the  uterus  may  be  swabbed  with  perchloride 
of  iron  or  packed  firmly  with  iodoform  gauze.  By  so  checking  the 
hemorrhage  the  blood  will  be  more  rapidly  restored  by  the  influences 
of  rest,  liberal  diet,  and  blood  tonics.  There  are  individual  cases 
demanding  immediate  surgical  interference  without  regard  to  the 
blood  and  the  general  resistance  of  the  individual.  In  such  cases  it 
is  usually  possible  to  choose  a  less  radical  procedure  which,  while  not 
promising  so  perfect  remote  results,  does  give  reasonable  assurance  of 
escape  from  the  immediate  dangers,  and  promises  such  a  bettering  of 
conditions  as  will  afford  a  later  opportunity  to  carry  out  a  mare  radical 
course  of  treatment.  For  example,  the  patient  is  anemic  and  septic 
from  a  suppurative  pelvic  infection;  vaginal  drainage  is  made,  leaving 
the  removal  of  the  involved  organs  to  a  later  date,  when  the  micro- 
organisms have  lost  their  virulence,  when  the  resistance  of  the  individual 
has  greatly  improved,  and  when  conservative  measures,  such  as  rest, 


SURGICAL  SHOCK  901 

douches,  and  glycerin  tampons,  have  accomplished  all  they  can  toward 
the  restoration  of  involved  structures. 

Again,  we  may  allude  to  cases  of  extra-uterine  pregnancy  in  which 
so  much  blood  has  been  lost  that  the  patient  is  rendered  extremely 
anemic;  such  cases  may  not  brook  delay,  but  call  for  a  radical  procedure 
in  the  face  of  grave  dangers. 

These  and  many  other  conditions  may  be  cited  wherein  radical 
operations  are  performed  in  times  of  emergency,  and  with  the  almost 
certain  result  of  grave  depression. 

Prolonged  fasting  and  vigorous  catharsis  practised  a  day  or  more 
before  the  operation  contribute  to  the  lowered  resistance  of  the  patient, 
and  should  be  judiciously  regulated. 

Furthermore,  the  practice  of  administering  strychnine  in  the  days 
preceding  an  operation  is  open  to  the  objection  that  such  patients  do 
not  respond  so  promptly  to  stimulation  after  operation. 

The  chilling  of  the  surface  of  the  body  has  been  mentioned  as  a 
factor  in  the  production  of  shock.  To  avoid  this  the  operating  room 
should  be  kept  at  a  uniform  temperature  of  80°  F.,  and  all  currents 
of  air  should  be  excluded.  The  extremities  and  chest  should  be  snugly 
wrapped  in  blankets,  and  no  part  of  the  body  should  be  exposed  to  the 
air  except  the  field  of  operation. 

Restorative  Treatment. — Too  much  dependence  must  not  be  placed 
in  such  stimulants  as  strychnine,  nitroglycerin,  camphor,  digitalis, 
caffeine,  and  whisky.  The  one  great  sheet-anchor  in  event  of  shock  is 
normal  salt  solution.  Whisky  or  brandy,  in  quantities  of  a  half-ounce 
to  two  ounces,  may  be  added  to  the  salt  solution,  with  good  effect. 
The  hypodermic  administration  of  the  sulphate  of  strychnine  in  doses 
of  -gV  to  -21J  grain,  repeated  every  two  to  four  hours,  is  a  valuable 
adjunct  to  normal  salt  solution.  Brown  Miller  extols  the  hypodermic 
injection  of  morphine,  i  to  ^  grain,  when  there  is  restlessness. 

The  bed  should  be  well  heated  with  hot-water  bottles,  and  a  liberal 
supply  of  blankets  should  be  provided. 

When  the  pulse  is  weak  it  has  been  common  practice  to  elevate  the 
head  of  the  bed  ten  to  twelve  inches.  Experience  has  proved  to  the 
author  that  in  this  position  the  heart  action  is  better,  there  is  less 
nausea,  less  distress  from  gas  pains,  and  the  urine  is  voided  with  less 
difficulty. 

The  following  instructions  are  given  the  nurses  to  guide  them  in  the 
care  of  any  patient  in  shock: 

1.  Elevate  foot  of  bed  twelve  inches. 

2.  Wrap  in  warm  blankets. 

3.  Place  hot-water  bottles  about  the  body  and  lower  extremities. 

4.  Give  enema  of  one  pint  salt  solution  and  two  ounces  of  whisky. 

5.  If  in  profound  shock,  give  subcutaneous  injections  of  normal  salt 
solution,  one  pint,  and  repeat  every  four  hours  while  in  shock. 

6.  H}T)odermic  injections  of  strychnine,  ^  grain,  every  four  hours. 

7.  Keep  room  at  a  temperature  of  80°  F.,  but  with  abundance  of 
fresh  air. 


902  COMPLICATIONS  FOLLOWING  OPERATIONS 

Crile  recommends  the  aqueous  extract  of  adrenalin  as  a  speedy 
though  evanescent  stimulant.  He  also  proposes  artificial  respiration 
as  a  vasomotor  and  heart  stimulant. 

Pulmonary  Embolism. — Pulmonary  embolism  is  an  accident  that 
cannot  be  foreseen,  and  places  the  surgeon  in  an  altogether  defenceless 
position.  We  are  indebted  to  ^Mahler  for  his  carefully  worked-out 
studies  in  the  pathology  and  clinical  signs  of  pulmonary  embolism 
following  gynecological  operations. 

Causes. — Thrombi  which  form  in  the  femoral  or  pelvic  veins  become 
dislodged  and  are  conveyed  to  the  lungs.  The  absence  of  valves  in 
the  veins  of  the  pelvis  accounts  for  the  frequency  of  pulmonary  embol- 
ism following  venous  thrombosis  of  the  pelvis.  Prominent  among  the 
causes  of  thrombosis  of  the  pelvic  veins  are  the  pelvic  infections  which 
involve  the  veins,  and  again,  the  anemias  which  result  from  the 
various  conditions  which  lead  to  uterine  hemorrhage. 

In  addition  to  these  causes  we  may  name  as  predisposing  factors 
a  retarded  circulation  from  the  pressure  of  tumors  in  the  pelvis,  incom- 
petent heart  action,  obstructive  diseases  of  the  liver,  lungs,  spleen, 
and  kidney. 

It  is  said  that  pelvic  thrombi  are  especially  liable  to  form  during 
the  course  of  cancer  of  the  uterus. 

Dearborn  reviews  the  work  of  twenty-five  surgeons  in  Boston  and 
vicinity,  and  concludes  that  thrombosis  and  embolism  more  frequently 
follow  gynecological  operations  than  operations  in  any  other  portion 
of  the  body.  He  believes  that  many  cases  of  pleurisy,  pneumonia, 
and  pulmonary  abscess  following  operations  are  due  to  pulmonary 
emboli.  Schenck  reported  48  cases  of  thrombosis  in  7130  gyneco- 
logical operations.  Gessner  reported  43  cases  of  pulmonary  embolism, 
of  which  number  18  were  operated  for  uterine  fibroids;  in  these  cases 
the  thrombi  were  the  result  of  pressure  of  the  growth  upon  the  veins. 
Gebele  reports  14  cases  of  pulmonary  embolism  in  1196  laparotomies. 
Burkhard  had  12  cases  in  236  myoma  operations,  while  Brown 
Miller  had  but  6  cases  in  7000  operations,  which  did  not  include  cases 
of  postoperative  pleurisy,  some  of  which  may  have  been  due  to 
,  embolism. 

The  dislodgement  of  a  thrombus  may  occur  during  the  operation, 
or  hours,  days,  and  weeks  thereafter.  Krusen  observes  that  almost 
all  fatal  cases  of  embolism  have  occurred  when  the  patient  was  doing 
well;  often  when  the  cure  was  considered  complete. 

Symptoms. — ^The  intensity  of  the  symptoms  is  in  direct  ratio  to  the 
size  and  number  of  the  emboli. 

"When  small  and  single  the  event  may  pass  unnoticed,  but,  as  a  rule, 
there  is  precordial  pain,  dyspnea,  and  a  quickened  pulse,  together  with 
fear  and  apprehension  on  the  part  of  the  patient.  When  the  emboli 
are  large  or  in  greater  numbers  these  symptoms  are  more  pronoimced. 
Not  only  does  the  degree  of  symptoms  depend  upon  the  size  and  number 
of  emboli,  but  as  well  upon  the  size  of  the  obstructed  vessel,  the  rapidity 
and  completeness  of  the  obstruction,  the  nature  of  the  embolism,  and 


ILEUS  903 

the  general  condition  of  the  patient,  with  particular  reference  to  the 
heart  and  kidneys. 

When  a  large  part  of  the  pulmonary  artery  is  suddenly  and  completely 
plugged,  death  may  be  instantaneous.  In  such  cases  the  patient  gasps 
for  breath,  is  seized  with  intense  precordial  pain,  the  heart  action  is 
usually  forceful,  but  may  be  weak  and  irregular,  the  face  becomes 
cyanotic,  and  death  is  preceded  by  coma.  Convulsions  and  opisthotonos 
are  occasionally  observed  to  immediately  precede  death. 

Treatment. — Prophylaxis  is  the  only  line  of  procedure  in  the  treatment 
of  these  cases.  The  frequency  of  the  accident  bespeaks  careful  prelim- 
inary preparation  in  the  way  of  increasing  the  general  nutrition. 

When,  because  of  local  tenderness,  pain,  and  edema  there  is  reason 
to  suspect  the  formation  of  pelvic  thrombi,  the  greatest  caution  is  to 
be  exercised  to  prevent  dislodgement.  The  patient  is  admonished 
to  lie  in  bed  for  a  longer  period  than  usual,  and  all  unnecessary 
manipulations  of  the  limb  are  avoided. 

When  phlebitis  develops  the  leg  must  be  immobilized  by  a  firm  but 
soft  bandage  of  cotton  flannel  and  elevated  on  pillows.  All  liniments 
and  massage  must  be  proscribed.  In  the  acute  stage  ice-bags  should 
be  applied  to  the  course  of  the  vein. 

Ileus. — Ileus  may  be  defined  as  a  temporary  or  permanent  paralysis 
of  the  intestinal  peristalsis.  It  is  known  to  arise  from  the  following 
causes : 

1.  Strangulation  of  the  bowel  by  intestinal  adhesions. 

2.  Incarceration  of  an  intestinal  loop  in  an  opening  in  the  omentum. 

3.  Strangulation  of  the  bowel  by  means  of  bands  formed  by  the 
fixation  of  the  uterus  to  the  abdominal  wall  or  about  septic  foci. 

4.  Volvulus. 

5.  Idiopathic. 

Symptoms. — Paroxysmal  griping  pains,  beginning  at  the  seat  of 
obstruction  and  increasing  in  intensity  and  frequency,  are  usually 
the  first  evidence  of  ileus.  The  peristaltic  wave  of  the  bowel  above 
the  point  of  obstruction  in  such  cases  may  be  seen  with  the  eye  and 
felt  with  the  hand.  When  the  obstruction  is  not  complete,  the  gas 
and  fluid  contents  of  the  bowel,  in  escaping  past  the  point  of  partial 
obstruction  may  produce  an  audible  gurgling  sound. 

All  efforts  to  evacuate  the  bowel  fail.  The  paroxysmal  pains  are 
soon  followed  by  nausea  and  vomiting,  which  becomes  fecal.  Tympany 
develops  and  becomes  extreme;  then  follows  rapid,  shallow  breathing 
and  embarrassed  heart  action. 

Exhaustion  is  the  inevitable  result;  the  face  becomes  pinched,  the 
eyes  sunken,  the  intellect  dulled,  the  pulse  rapid  and  feeble.  As 
dissolution  approaches  the  vomiting  ceases  and  the  patient  becomes 
quiet.  Death  is  the  result  of  exhaustion  or  of  peritonitis,  arising  from 
a  gangrenous  gut.  . 

Diagnosis.— It  is  of  the  greatest  importance  to  recognize  the  condition 
before  the  strength  of  the  patient  is  exliausted  and  the  bowel  becomes 
gangrenous. 


904  COMPLICATIONS  FOLLOWING  OPERATIONS 

In  gaseous  distention  of  the  bowel,  particularly  when  there  is  a  relaxed 
condition  of  the  abdominal  walls  which  permits  of  great  distention  of 
the  abdomen,  fear  is  often  entertained  lest  an  ileus  be  present.  The 
abdominal  pains,  distention  of  the  abdomen,  nausea  and  vomiting, 
embarrassed  respiration,  and  obstipation  present  a  clinical  picture 
that  closely  simulates  ileus.  However,  the  general  depression  is  never 
so  marked  and  efforts  to  move  the  bowel  will  eventually  be  successful. 

The  clinical  differentiation  of  peritonitis  from  ileus  may  be  impossible ; 
as  a  matter  of  fact,  the  two  conditions  frequently  coexist  or  one  follows 
the  other.  Rise  in  temperature  is  in  favor  of  peritonitis;  while  not 
invariably  present  in  peritonitis,  it  is  the  rule,  while  in  ileus,  independent 
of  infection,  there  is  little  or  no  rise  in  temperature.  The  peculiar  and 
rather  characteristic  paroxysms  of  pain  in  ileus  are  not  present,  as  a 
rule,  in  peritonitis.  In  peritonitis  the  pain  is  more  diffuse  and  continuous. 

Treatment. — Prophylaxis  is  of  paramount  importance  in  that  much 
can  be  done  to  prevent  the  development  of  ileus. 

In  the  breaking  up  of  adhesions  within  the  abdomen  all  raw  surfaces 
should  be  carefully  covered  with  peritoneum  as  far  as  possible,  and 
when  this  cannot  be  done  the  raw  surfaces  should  be  charred  with  a 
Paquelin  cautery.  The  author  has  had  repeated  opportunities  to  observe 
the  after-effects  of  charring  a  raw  surface  with  the  thermocautery  in 
cases  which  were  opened  for  the  second  time  several  months  after  the 
initial  operation,  in  which  adhesions  were  broken  up  and  the  raw  surfaces 
were  cauterized.  In  all  of  these  cases  few  if  any  adhesions  reformed  on 
the  charred  surfaces. 

Not  all  intestinal  adhesions  should  be  broken  up.  Unless  they  are 
evidently  causing  disturbance  it  is  not  advisable  to  disturb  them, 
because  they  may  re-form  in  such  a  manner  as  to  cause  obstruction. 

One  of  the  objections  to  ventrosuspension  of  the  uterus  is  the  false 
band  which  develops  and  is  liable  to  strangulate  the  bowel.  The  same 
objection  is  made  to  the  Gilliam  operation  of  suspending  the  uterus 
by  the  round  ligaments. 

Omental  tears  should  be  restored  for  fear  of  strangulation  of  the 
bowel  through  the  opening. 

The  utmost  care  must  be  taken  in  coapting  the  peritoneal  surfaces 
in  the  closure  of  the  abdominal  incisions.  The  peritoneal  margins 
should  be  everted  if  adhesions  to  the  bowel  and  omentum  are  to  be 
avoided. 

Care  should  be  taken  not  to  handle  the  bowel  roughly,  as  in  mopping 
with  sponges,  for  fear  of  creating  adhesions.  Dry  sponges  should  be 
avoided. 

Whenever  coils  of  bowels  are  adherent  in  such  a  manner  as  to 
cause  partial  obstruction,  they  must  be  released  and  all  knuckles  of 
bowel  straightened  out,  and  the  raw  surfaces  covered  with  peritoneum 
or  charred  with  the  cautery.  Filling  of  the  abdomen  with  salt  solution 
after  the  completion  of  an  operation,  and  immediately  before  the  last 
peritoneal  stitches  are  taken  in  closing  the  abdominal  incision,  will 
favor  the  readjustment  of  the  coils  of  bowel. 


ILEUS  905 

Conservative  Treatment. — Conservative  treatment  may  be  persisted 
in  so  long  as  the  vomiting  is  not  stercoraceous,  the  pulse  increasing 
in  rate,  and  the  strength  failing.  Up  to  this  point  efforts  may  be 
persisted  in  to  force  the  opening  of  the  bowel  by  the  administration  of 
calomel  and  salts  in  repeated  small  doses,  and  by  the  use  of  enemata. 

Calomel  and  soda  bicarbonate  in  half-grain  doses  may  be  repeated 
hourly  until  four  grains  are  given,  then  discontinued  for  twelve  to 
eighteen  hours,  and  again  continued  for  a  like  period  of  time.  Epsom 
salts  may  be  given  in  one  to  two  hours  following  the  last  dose  of 
calomel. 

Turpentine  enemata,  1  dram  to  1  pint  of  warm  water,  may  be  given 
one  or  more  times  daily.  An  efficient  enema  will  be  found  in  one  pint 
each  of  warm  milk  and  molasses. 

After  persisting  in  this  treatment  for  two  or  three  days,  or  until 
the  condition  of  the  patient  fails  to  improve,  but,  on  the  contrary, 
proceeds  unfavorably,  all  tentative  measures  must  be  abandoned  and 
radical  measures  adopted. 

Operative  Treatment. — Every  possible  precaution  should  be  taken  to 
prevent  the  further  lowering  of  the  resistance  of  the  patient.  The 
operating  room  should  be  at  a  temperature  of  80°  F.,  and  the  body 
wrapped  in  warm  blankets.  The  stitches  are  removed  and  the  abdomi- 
nal wound  spread  open.  A  thorough  digital  and  ocular  examination 
should  be  made  of  the  abdominal  and  pelvic  viscera,  and  if  necessary 
the  intestines  are  removed  from  the  abdomen  and  covered  with  hot 
towels.  One  should  not  be  content  with  the  finding  of  a  single  cause 
for  obstruction,  but  the  search  must  be  continued  until  all  possible 
causes  are  excluded.  In  examining  the  loops  of  bowel,  proceed  in  an 
orderly  manner  from  below  upward  until  all  parts  of  the  bowel  have 
been  inspected.  When  the  bowel  has  been  so  injured  as  to  suggest  a 
possible  source  of  infection,  abdominal  drainage  should  be  established 
as  a  precautionary  measure. 

When  the  peritoneal  covering  of  the  bowel  has  been  partially  stripped 
off  it  may  be  stitched  back  upon  the  bowel  with  No.  1  plain  catgut. 
Injuries  to  the  muscular  coat  of  the  bowel  are  more  securely  repaired 
with  silk  or  linen. 

When  there  is  great  distention  of  the  gut  it  may  be  advisable  to  open 
the  bowel  as  described  under  peritonitis.  If  gangrene  exists  the  affected 
gut  is  excluded  from  the  peritoneal  cavity  by  stitching  the  bowel  to 
the  abdominal  incision  and  incising  it  after  adhesions  have  formed. 

If  the  mesentery  has  been  so  injured  as  to  shut  off  any  considerable 
blood  supply  to  the  bowel,  the  only  safe  procedure  is  to  resect  that 
portion  of  the  bowel  which  has  been  robbed  of  its  supply. 

The  abdomen  is  closed  with  through-and-through  silk  or  silkworm- 
gut  sutures  and  a  fresh  dressing  applied. 

The  usual  stimulants  are  administered  following  the  operation. 
Drastic  measures  should  not  be  employed  to  move  the  bowel  after  the 
operation;  if  the  obstruction  has  been  removed  there  will  usually  be  a 
spontaneous  evacuation  of  the  bowel  within  twenty-four  hours. 


906  COMPLICATIONS,  FOLLOWING  OPERATIONS 

Adynamic  or  paralytic  ileus  presents  no  lesion  other  than  the  dis- 
tended bowel.  It  seldom  occurs,  and  there  is  no  known  cause.  Inju- 
ries to  the  mesenteric  nerves,  the  prolonged  administration  of  opiates, 
prolonged  exposure  of  the  intestines  to  air  and  to  handling,  and  rapidly 
developing  peritonitis  and  toxemia,  are  supposed  causal  factors. 

Pneumonia. — Pneumonia  may  follow  upon  an  operation  within  a 
few  hours,  but,  as  a  rule,  not  before  the  third  to  seventh  day. 

Causes. — The  predisposing  causes,  so  far  as  known,  are  chilling  of 
the  surface  of  the  body  before,  during,  and  after  the  operation;  irritating 
properties  of  an  anesthetic,  notably  of  ether;  inhalation  of  foreign 
substances  during  the  anesthetic;  intemperance,  prolonged  recumbent 
position,  season  of  the  year,  embolic  infarction  of  the  lungs  emanating 
from  foci  in  the  pelvis,  and  the  awakening  of  latent  or  localized  infections 
of  the  respiratory  tract.  Postoperative  pneumonia  occurs  no  more 
frequently  after  laparotomies  than  after  vaginal  operations. 

Advanced  age  is  a  predisposing  factor;  Doderlein  found  27  of  his 
100  cases  of  pneumonia  following  laparotomy  were  in  women  over 
seventy  years  of  age;  this  was  opposed  to  3  or  4  per  cent,  in  girls,  whose 
ages  ranged  from  eleven  to  twenty  years. 

According  to  Lindermann  and  Holscher,  ether  is  not  directly  irritating 
to  the  bronchial  mucous  membrane,  but  excites  an  excessive  secretion 
of  mucus  in  the  throat,  which  in  turn  sets  up  a  pneumonia.  It  has 
been  clearly  shown  in  the  clinic  of  Mikulicz  that  postoperative  pneu- 
monia is  almost  invariably  due  to  the  inspiration  of  mucus  and  foreign 
particles  into  the  bronchi,  hence  the  anesthetic  which  produces  the 
greatest  secretion  in  the  throat  is  most  likely  to  be  followed  by  pneu- 
monia. More  than  this,  all  conditions  which  embarrass  expectoration 
after  operation  predispose  to  pneumonia;  such,  for  example,  is  general 
weakness,  pain  on  exertion,  weakened  heart  action,  coma,  delirium, 
tight  binding  of  the  chest  and  abdomen,  and  tympany  which  embar- 
rasses the  excursions  of  the  diaphragm. 

That  a  large  number  of  lung  complications  following  operations  are 
due  to  the  anesthetic  is  evidenced  by  the  statistics  of  Mikulicz,  who 
found  in  1005  laporotomies  -performed  under  general  anesthesia  that 
the  pneumonic  morbidity  was  7.5  per  cent,  and  the  mortality  3.4  per 
cent. 

The  essential  factors  in  the  development  of  pneumonia  are  the 
pathogenic  bacteria,  of  which  may  be  mentioned  the  bacillus  coli 
communis,  bacillus  pneumonise  of  Friedlander,  pyogenic  cocci,  and  the 
micrococcus  lanceolatus. 

~  Pathology. — In  52  postmorten  examinations  of  postoperative  infec- 
tions of  the  lungs  following  abdominal  sections,  7  showed  a  fibrinous 
lobar  pneumonia,  17  a  gangrenous  condition  of  the  lungs,  2  a  sero- 
fibrinous pleuritis  without  changes  in  the  lungs,  and  in  5  there  were 
pulmonary  emboli. 

Symptoms. — The  time  of  onset  of  postoperative  pneumonia  varies 
greatly.  When  due  to  the  anesthetic  the  symptoms  are  usually  manifest 
by  the  end  of  the  first  twenty-four  hours,  while  septic  pneumonia, 


POSTOPERATIVE  PLEURISY  907 

due  to  embolic  infarction  is  not  usually  manifest  prior  to  the  seventh 
day,  and  may  be  as  late  as  the  second  and  third  weeks. 

The  clinical  signs  and  symptoms  do  not  differ  essentially  from  those 
of  the  ordinary  forms  of  pneumonia.  The  increase  in  the  respiratory 
rate,  the  pain  in  the  chest,  the  mucopurulent  expectoration,  and  the 
ph^^sical  signs  of  consolidation  may  all  be  present,  though  they  are  by 
no  means  constant.  Death  may  occur  and  the  autopsy  may  give  the 
first  intimation  of  an  involvement  of  the  lungs. 

In  pneumonia  due  to  anesthesia  the  prognosis  is  relatively  good, 
but  in  septic  pneumonia  the  outlook  is  always  grave. 

Treatment. — Prophylactic  treatment  is  of  the  highest  value,  for  much 
can  be  done  in  the  way  of  preventing  postoperative  pneumonia. 

The  temperature  of  the  operating  room  should  not  be  below  70°  F., 
and  all  draughts  of  air  should  be  excluded.  The  trunk  and  lower 
extremities  should  be  wrapped  in  warm  blankets.  Throughout  the 
first  week  of  convalescence  the  sick  room  should  be  kept  at  a  uniform 
temperature  of  70°  to  75°  F.,  and  no  draughts  should  be  permitted. 
No  patient,  save  in  an  emergency,  should  be  operated  when  suffering 
from  an  acute  irritation  of  the  respiratory  tract,  and  in  chronic  infec- 
tions of  the  throat,  bronchi,  and  lungs,  chloroform  should  be  chosen  in 
preference  to  ether. 

Unless  contra-indicated  the  author  administers  a  h\^odermic  injection 
of  morphine  sulphate,  |  grain,  and  atropia  sulphate,  yi-o  grain,  thirty 
minutes  before  the  anesthetic  is  started.  This  lessens  the  amount  of 
mucus  secreted  in  the  throat,  and  thus  becomes  an  important  factor 
in  the  prevention  of  postoperative  pneumonia.  No  anesthetic  should 
be  given  in  the  presence  of  food  in  the  stomach,  and  hence  no  solid 
food  should  be  taken  for  twenty-four  hours  preceding  the  operation. 
In  cases  of  emergency  the  stomach  should  be  washed  out  before  the 
administration  of,  an  anesthetic.  A  good  procedure  is  to  encourage 
the  patient  to  drink  large  quantities  of  water  up  to  one  hour  before 
the  operation;  this  will  cleanse  the  stomach  and  do  much  to  prevent 
vomiting  both  during  and  after  the  operation. 

The  prevention  of  vomiting  and  the  filling  of  the  throat  with  mucus 
is  largely  under  the  control  of  the  anesthetizer.  When  mucus  fills 
the  throat  it  should  be  immediately  swabbed  out  with  bits  of  sterile 
gauze  grasped  by  forceps. 

A  warm  flannel  jacket  worn  after  the  operation  will  protect  the 
chest. 

The  active  treatment  of  postoperative  pneumonia  does  not  differ 
essentially  from  that  of  ordinary  forms  of  pneumonia.  The  reader  is 
referred  to  standard  works  on  internal  medicine. 

Acute  Bronchitis.— Acute  bronchitis  is  a  frequent  postoperative 
complication.  It  may  be  independent  of  or  combined  with  pneumonia. 
The  causes  are  the  same  as  for  pneumonia.  The  symptoms  and  treat- 
ment do  not  differ  from  those  of  the  non-operative  t^'pes. 

Postoperative  Pleurisy.— Postoperative  pleurisy,  independent  of 
pneumonia,  embolism,  and  tuberculosis  of  the  lungs  and  pleura,  is  an 


908  COMPLICATIONS  FOLLOWING  OPERATIONS 

unusual  occurrence  as  compared  with  the  number  of  cases  so  diagnos- 
ticated. The  fact  that  these  cases  almost  invariabl}'  recover  leaves 
one  in  doubt  as  to  the  actual  frequency  of  the  lesion. 

The  acute  lesion  occasionally  results  from  the  awakening  of  a  latent 
tuberculosis  of  the  pleura.  INIore  commonly  the  infection  begins  in 
the  lungs  and  extends  to  the  pleura. 

Symptoms. — The  symptoms  of  postoperative  pleurisy  are  those  com- 
mon to  the  ordinary  type.  There  is  the  sharp  lancinating  pain  in  the 
chest  that  is  aggravated  by  deep  breathing,  the  hacking  cough, 
the  temperature  rising  to  a  variable  degree,  though  seldom  high, 
and  the  friction  rub  detected  over  the  painful  area.  Prophylaxis 
does  not  differ  from  that  of  pneumonia,  and  the  active  treatment  is 
that  laid  down  in  text-books  on  internal  medicine. 

Gangrene  of  the  Lungs. — Gangrene  of  the  lungs  is  fortunately  a  rare 
complication.  It  usually  arises  from  the  aspiration  of  vomitus  during 
the  anesthetic.  Emboli  containing  putrefactive  bacteria  may  give 
rise  to  the  lesion.  The  diagnosis  from  other  lung  affections  is  largely 
arrived  at  by  the  character  of  the  sputum,  which  is  fetid  and  of  a 
greenish  color. 

Abscess  of  the  Lung. — Abscess  of  the  lung  is  of  less  common  occur- 
rence than  gangrene  if  we  exclude  the  complications  of  general  pyemia. 

Pulmonary  Edema. — Pulmonary  edema  may  arise  from  the  irritating 
action  of  the  anesthetic  upon  the  lung  and  from  paralysis  of  the  vaso- 
motor centre.  An  incompetent  heart  and  kidney  predispose  to  the 
condition. 

Noble  believes  that  an  overfilling  of  the  bloodvessels  with  salt 
solution  predisposes  to  edema  of  the  lungs,  also  that  filling  the 
abdominal  cavity  with  salt  solution  and  elevating  the  foot  of  the 
bed  aggravate  and  may  originate  the  condition. 

Local  and  General  Infections. — Local  Infections. — Of  the  local 
infections  the  most  common  is  the  so-called  stitch  abscess.  A 
thick  abdominal  wall  is  particularly  prone  to  suppurate,  inasmuch 
as  such  infections  commonly  take  their  origin  in  the  fatty  tissues. 
A  number  of  conditions  predispose  to  the  development  of  septic  foci 
in  and  about  the  abdominal  incision.  First  in  point  of  frequency 
is  a  lack  of  surgical  cleanliness  in  the  preparation  of  the  suture 
material,  gauze,  and  instruments,  in  the  preparation  of  the  field 
of  operation  and  hands  of  the  operator  and  assistants,  and  in  faulty 
technic  on  the  part  of  the  surgeon.  Less  common  causes  are  the  too 
tight  tying  of  the  sutures,  the  leaving  of  dead  spaces  in  the  abdominal 
~wall  through  failure  to  accurately  approximate  the  various  layers  in 
the  abdominal  incision,  and  finally  through  the  rough  handling  of  the 
tissues  by  the  retractors  and  hands  of  the  operator  and  assistants. 

These  infections  may  give  rise  to  no  symptoms,  and  may  not  be 
suspected  until  the  dressings  are  removed  for  the  purpose  of  taking 
out  the  stitches.  As  a  rule,  however,  there  is  an  elevation  of  tem- 
perature amounting  to  1°  or  2°,  beginning  about  the  third  or  fourth 
day,  together  with  some  discomfort  at  the  site  of  the  incision.    The 


LOCAL  AND  GENERAL  INFECTIONS  909 

pulse  does  not  rise  proportionate  to  the  degree  of  fever.  If  the  septic 
focus  is  superficial,  tenderness,  redness,  and  edema  will  mark  the  loca- 
tion. Large  quantities  of  pus  may  be  buried  deeply  in  the  abdominal 
wall  in  the  absence  of  any  superficial  evidence  of  infection,  and  with 
slight  rise  of  temperature;  such  abscesses  are  usually  located  in  the 
adipose  tissue  of  the  abdominal  wall.  When  the  pus  burrows  into 
the  muscular  wall  the  tension  is  great,  and  hence  the  early  rise  of  tem- 
perature and  pain.  Such  abscesses  may  fail  to  open  externally;  they 
may  burrow  far  and  wide,  and  have  been  known  to  open  into  the 
abdominal  cavity,  and  to  result  fatally.  Kelly  reported  three  such 
cases  occurring  in  the  Johns  Hopkins  Hospital. 

If  the  abscess  is  not  recognized  and  drainage  established,  it  will 
usually  find  its  way  to  the  surface  and  break  externally  within  five 
to  twenty  days. 

When  the  temperature  rises  after  the  third  day  of  an  operation  the 
wound  should  be  carefully  inspected.  If,  at  the  site  of  one  or  more 
stitches,  there  is  found  an  area  that  is  reddened,  indurated,  and  tender, 
a  stitch  should  be  removed  and  the  involved  area  explored  with  a 
grooved  director  in  the  efi^ort  to  disclose  the  presence  of  pus.  If  pus  is 
found,  free  drainage  must  be  established  by  removing  the  necessary 
number  of  stitches  and  opening  up  the  abscess  cavity  through  the  line 
of  incision.  Sterile  gauze  dressings  are  then  applied;  these  are  reapplied 
as  often  as  may  be  required  to  keep  the  abscess  empty  and  the  surface 
free  of  accumulated  secretion.  Peroxide  of  hydrogen  is  extensively 
used  as  an  injection  into  abscess  cavities.  This  preparation  is  of  special 
value  when  the  abscess  is  sinuous.  When  the  inflammatory  reaction 
is  widespread  it  is  well  to  apply  hot  antiseptic  fomentations;  for  this 
purpose  an  effective  combination  is  hot  sterile  water  2000  parts,  glycerin 
40  parts,  and  formalin  1  part.  With  such  infections  there  is  always 
the  subsequent  danger  of  spreading  of  the  scar  along  the  line  of  incision. 
To  avoid  this  the  tension  should  be  relieved  by  strapping  the  abdomen 
with  adhesive  strips,  which  pass  from  the  sides  of  the  abdomen  over 
the  dressings  covering  the  incision.  After  the  wound  has  healed  and 
the  stitches  are  removed,  an  elastic  abdominal  support  should  be  worn 
for  several  months,  removing  it  only  when  retiring  for  the  night. 

The  author  has  observed  wounds  to  appear  perfectly  healed  and 
without  pain  or  temperature,  yet  at  the  end  of  a  period  of  days 
and  possibly  weeks  an  abscess  has  opened  upon  the  surface.  He  has 
credited  this  mishap  to  the  presence  of  chromic  catgut  placed  in  the 
deep  fascia,  and  for  this  reason  he  now  seldom  employs  chromic  catgut 
in  suturing  abdominal  incisions. 

Peritonitis. — For  the  discussion  of  peritonitis  see  Chapter  XXI. 

Fermentation  Fever. — Fermentation  fever  is  a  term  which  dates 
back  to  the  time  of  Billroth  and  von  Bergmann,  who  characterized  this 
type  of  infection  as  one  caused  by  the  absorption  of  ferment  products 
into  the  circulation.     Mild  febrile  symptoms  were  credited  to  this 

cause.  1       p       •      1 

Angerer  and  Edelberg  injected  into  the  bloodvessels  ot  anmials 


910  COMPLICATIONS  FOLLOWING  OPERATIONS 

definite  quantities  of  blood  containing  fibrin  ferments,  and  thereby 
produced  a  slight  rise  in  temperature;  the  conclusion  was  that  the 
absorption  of  fibrin  ferments  was  responsible  for  the  slight  febrile 
reactions  following  operations. 

This  so-called  fermentation  fever  usually  sets  in  within  the  first 
twenty-four  hours  following  operation;  it  seldom  exceeds  101°  F.,  and 
continues  one  to  four  days,  then  gradually  recedes  to  the  normal. 
Occasionally  the  temperature  is  found  at  99°  to  100°  F.  at  some  time 
in  the  afternoon  for  two  to  four  weeks.  The  febrile  reaction  is  usually 
in  direct  proportion  to  the  extent  of  the  operation. 

No  doubt  the  term  "fermentation  fever"  is  loosely  applied,  and  in 
reality  embraces  all  sorts  of  infection  of  low  virulence.  All  varieties 
of  bacteria  can  give  rise  to  such  a  condition,  and,  moreover,  certain, 
not  generally  recognized  anaerobic  microorganisms  which  fail  to  grow  on 
the  ordinary  culture  media,  also  may  give  rise  to  this  form  of  fever.  It 
is,  therefore,  self-evident  that  the  term  fermentation  fever  is  ill  advised, 
and  serves  as  a  cloak  for  ignorance. 

Septic  Intoxication. — Septic  intoxication  is  another  term  loosely 
employed  and  capable  of  misapplication.  It  is  intended  to  designate 
that  form  of  infection  which  is  dependent  upon  a  septic  focus  from 
which  toxins  are  absorbed  into  the  general  circulation. 

Symptoms. — The  onset  of  the  symptoms  is  usually  gradual,  the 
fever  may  rise  to  an  alarming  degree,  and  result  fatally.  In  such  cases 
the  temperature  may  rise  to  105°  F.,  the  pulse  to  140  to  180.  The 
later  the  signs  of  infection  become  manifest  the  greater  the  supposition 
that  there  is  a  focus  of  infection  developing  in  the  tissues  from  which 
toxins  are  being  absorbed. 

Prognosis. — The  prognosis  is  dependent  upon  the  variety  of  infecting 
microorganisms,  their  number  and  virulence,  the  location  of  the  area 
of  infection,  and  the  absorbing  and  resisting  powers  of  the  tissues. 
It  is  possible  for  death  to  occur  within  a  few  hours. 

Treatment. — The  management  of  these  cases  must  be  prompt  and 
intelhgent.  The  focus  of  infection  must  be  sought  and  efficient  drainage 
established.  With  this  accomplished  the  septic  intoxication  will  take 
care  of  itself,  unless  extreme,  when  elimination  of  the  toxins  must  be 
accomplished  by  promoting  the  secretions  of  the  bowel,  skin,  and 
kidneys.  This  is  done  by  the  administration  of  saline  cathartics, 
enteroclysis,  or  hypodermoclysis  and  hot  packs.  For  stimulation, 
whisky  and  strychnine  should  be  administered. 

Septicemia. — True  septicemia  is  a  form  of  toxemia  in  which  the 
microorganisms  exist  and  multiply  in  the  blood.  It  has  been  described 
as  a  "disease  without  demonstrable  lesions,"  but  such  a  definition  will 
not  hold,  inasmuch  as  the  site  of  the  initial  infection  always  reveals 
microscopic  changes;  furthermore,  as  a  result  of  general  intoxication, 
parenchymatous  changes  exist  throughout  the  body. 

The  streptococcus  is  notably  disposed  to  cause  septicemia,  though 
other  microorganisms  are  occasionally  observed  to  do  so,  i.  e.,  the 
staphylococcus  pyogenes  albus,  aureus,   and  citreus,   colon  bacillus, 


BREAKING  OF  STITCHES  911 

bacillus  typhosus,  gonococcus,  proteus  vulgaris,  micrococcus  lanceolatus, 
and  the  bacillus  of  Friedlander. 

Pyemia. — The  characteristic  feature  of  pyemia  is  the  distribution 
of  metastatic  abscesses  remote  from  the  original  point  of  infection. 

Pyogenic  bacteria  and  infected  thrombi  gain  access  to  the  blood- 
stream, and  are  deposited  in  various  tissues  and  organs  of  the  body, 
there  to  develop  abscesses  containing  the  same  variety  of  germs  as 
found  in  the  original  site  of  the  infection. 

There  are  wide  excursions  in  temperature,  varying  from  normal  at 
some  hour  of  the  day  to  105°  F.  at  other  hours  of  the  same  day.  The 
time  of  rise  of  temperature  is  inconstant,  but,  as  a  rule,  the  maximum 
is  reached  about  noon,  and  by  evening  the  temperature  has  fallen  to 
near  the  normal.  The  pulse  is  relatively  rapid,  but  follows  the  excursions 
of  the  temperature.  There  is  marked  leucocytosis,  and  cultures  may 
be  obtained  from  the  blood.  Seldom  do  such  cases  recover,  death  being 
the  result  of  focal  abscesses  leading  to  general  exhaustion. 

It  is  seldom  that  pyemia  develops  independent  of  puerperal  infection. 
Endocarditis  and  metastatic  abscesses  are  characteristic  lesions  of  this 
sort  of  infection.    No  lesion  may  be  demonstrable  in  the  pelvic  viscera. 

No  portion  of  the  body  is  exempt  from  the  invasion  of  septic  emboli 
and  the  development  of  metastatic  abscesses. 

Treatment. — The  treatment  of  septicemia  and  pyemia  consists  in 
supporting  the  patient  by  a  nutritious,  easily  digested  diet,  and  by 
liberal  doses  of  strychnine  and  whisky.  Antistreptococcic  serum  in 
large  doses  should  be  given  early  in  the  course  of  the  infection. 

All  metastatic  abscesses,  if  accessible,  should  be  opened  and  drained, 
and  finally  palliative  measures  should  be  employed  to  render  the 
patient  as  comfortable  as  possible.  The  temperature  may  be  controlled 
by  cold  sponging.  Fresh  air  and  nourishing  food  are  the  most  essen- 
tial factors  in  the  management  of  these  cases.  Little  dependence  can 
be  placed  on  serums  and  vaccines. 

Breaking  of  Stitches. — It  is  possible  for  the  wound  to  open  by  the 
giving  way  of  the  stitches.  The  author  has  personal  knowledge  of 
two  such  cases.  Brown  Miller  refers  to  10  cases  known  to  him,  and 
to  157  cases  reported  by  Madelung.  It  is  therefore  fair  to  assume  that 
the  accident  occurs  more  often  than  we  are  aware. 

We  may  say  that  faulty  closure  of  the  wound  is  the  usual  underlying 
cause  of  the  accident.  If  the  suture  materials  are  reliable,  the  wound 
closes  properly,  and  the  abdomen  is  securely  supported  by  bandages, 
no  amount  of  exertion  on  the  part  of  the  patient  should  cause  the 
suture  to  give  way. 

At  the  time  when  abdominal  incisions  were  closed  by  through-and- 
through  sutures  of  silkworm  gut  or  silk,  the  accident  was  more  liable 
to  occur  than  now  when  layer  after  layer  of  catgut  is  used,  and  when  the 
abdominal  wall  is  thick,  interrupted  stay  sutures  of  linen,  silk,  or 
silkworm  gut  are  used. 

The  common  practice  of  strapping  the  abdomen  with  strips  of 
adhesive  plaster  and  placing  over  this  a  well-fitting  muslin  binder  adds 


912 


COMPLICATIONS  FOLLOWING  OPERATIONS 


much  to  the  security  of  the  wound.  A  selection  of  suture  materials 
with  strong  tension  power  is  of  importance. 

The  wound  has  been  known  to  separate  as  late  as  the  ninth  day, 
and  in  the  absence  of  suppuration.  When  suppuration  of  the  wound 
occurs  in  wounds  closed  with  catgut  and  not  supported  by  through- 
and-through  sutures  of  non-absorbable  material,  special  attention  must 
be  given  the  supporting  strips  of  adhesive  plaster  for  fear  of  complete 
separation  of  the  wound.  Madelburg  says  the  critical  days  are  the 
eighth  and  ninth  after  operation. 

In  both  cases  observed  by  the  author  the  greater  part  of  the  small 
bowel  extruded  through  the  incision.  A  loop  of  gut  may  protrude 
into  but  not  through  the  incision,  and  a  plastic  exudate  may  organize 
about  the  protruding  gut  and  omentum.  Death  is  the  result  of  stran- 
gulation of  the  bowel  or  peritonitis. 

Treatment. — ^The  treatment  depends  upon  the  conditions  found.  If 
there  is  no  infection  visible  the  gut  is  replaced,  drainage  established, 
and  the  edges  of.  the  incision  freshened  and  again  sutured.  When 
pus  exists  and  is  walled  off  from  the  general  peritoneal  cavity,  care 
should  be  taken  to  avoid  entering  the  peritoneal  cavity;  free  drainage 
is  established  and  the  wound  approximated  by  adhesive  straps. 

When  general  peritonitis  or  obstruction  of  the  bowel  exists,  the 
general  line  of  treatment  proposed  in  the  previous  pages  should  be 
followed. 

Fig.  622 


Iodoform  gauze  dressing  held  in  place  by  tying  interrupted  silkworm-gut  sutures  over  the  gauze. 


Closure  of  the  Abdominal  Wall. — Figs.  623  to  626  present  a  well- 
accepted  method  of  closure  of  the  abdominal  wall.  The  several  layers 
of  the  abdominal  wall  are  accurately  coapted  without  undue  tension. 
When  the  abdominal  wall  is  thick  or  when  there  is  great  intra-abdominal 
pressure,  the  author  usually  passes  two  to  four  interrupted  silkworm- 
gut  sutures  after  closing  the  peritoneum.  These  sutures  axe  passed 
through  all  structures  with  the  exception  of  the  peritoneum.  They 
are  not  tied  until  the  wound  is  completely  closed  (Fig.  622),  then 
several  layers  of  iodoform  gauze  are  placed  over  the  line  of  suture 
and  the  silkworm-gut  sutures  are  tied  over  the  gauze.  This  provides 
a  permanent  dressing,  and  prevents  the  cross-marks  of  the  sutures. 


POSTOPERATIVE  HERNIA 


913 


Postoperative  Hernia.— The  careful  coaptation  of  the  various 
structures  which  form  the  abdominal  wall  by  means  of  catgut  sutures 
and  the  exclusion  of  infecting  microorganisms  have  done  much  to 
eliminate  postoperative  hernia. 


Fig.  623 


Fig.  624 


Closure  of  the  abdominal  incision.  Con- 
tinuous suture  of  No.  1  plain  catgut  in  the 
peritoneum. 


Closure  of  the  abdominal  incision.  Contin- 
uous suture  of  No.  2  plain  catgut  in  the 
sheath  of  the  recti  muscles. 


Other  measures  tend  to  prevent  the  occurrence  of  hernia  in  the 
line  of  incision.  In  this  connection  may  be  mentioned  the  application 
of  adhesive  straps  in  the  dressing  of  the  wound  after  operation  (Fig. 
612),  and  the  wearing  of  an  elastic  abdominal  supporter  for  three  to 
six  months  following  an  abdominal  section  (Fig.  621). 

The  greater  the  thickness  of  the  abdominal  wall  the  greater  the 
liability  to  postoperative  hernia,  and  hence  the  greater  need  for  careful 
coaptation  of  the  various  layers  of  the  abdominal  wall,  of  excluding 
infection,  and  of  wearing  an  abdominal  support  subsequent  to  operation. 

Abdominal  drainage  should  be  excluded  whenever  possible,  if  for 
no  otLer  reason  than  that  drainage  predisposes  to  the  development 
of  hernia. 
58 


914 


COMPLICATIONS  FOLLOWING  OPERATIONS 


The  size  of  such  hernise  may  be  that  of  the  patient's  head.  The 
contents  are  omentum  and  loops  of  the  small  bowel,  one  or  both. 
These  structures  may  be  adherent  to  the  hernial  sac,  and  therefore 
become  incapable  of  reduction. 


Fig.  625 


Fig.  626 


Closure  of  the  abdominal  incision.  Contin- 
uous suture  of  No.  0  plain  catgut  in  the  sub- 
cutaneous fat.     To  be    used   only   when   the 

abdominal  wall  is  thick. 


Closure  of  the  abdominal  incision.  Mat- 
tress suture  of  horse-hair  to  approximate 
the  skin. 


Treatment. — There  is  no  encouragement  in  the  effort  to  support 
the  hernia  by  padded  abdominal  binders.  In  spite  of  all  that  can  be 
done  the  hernia  may  enlarge.  Operative  treatment  should  therefore 
be  early  instituted,  and  the  earlier  the  operation  is  performed  the 
better. 

Technic  of  Operation. — An  oval  incision  is  made  about  the  base 
of  the  hernia.  This  should  be  made  with  great  caution  for  fear  of 
injuring  the  bowel,  which  commonly  lies  immediately  beneath  the 
skin  and  subcutaneous  connective  tissue.  The  peritoneum  is  cautiously 
incised,  for  it  often  happens  that  the  bowel  lies  adherent  to  it.  "With 
the  index  and  middle  finger  inserted  through  the  peritoneal  incision 
as  a  guide,  the  operator  opens  the  peritoneum  in  the  line  of  the  skin 


POSTOPERATIVE  HERNIA 


915 


incision,  then  removes  the  entire  oval  flap,  consisting  of  skin,  subcuta- 
neous connective  tissue,  and  peritoneum.  This  leaves  an  oval  opening 
into  the  free  abdominal  cavity.  All  adhesions  binding  the  omentum  and 
bowel  must  be  freed  by  fingers  or  scissors.  If  a  large  portion  of  the 
omentum  protrudes  into  the  hernial  sac  it  should  be  hgated  with 
catgut  and  amputated,  taking  care  that  the  stump  of  omentum  is  rolled 
in  so  that  adhesions  cannot  form. 

^  A  gauze  pad  is  placed  over  the  bowel  while  dissecting  out  the  fibrous 
ring.  In  order  that  the  rectus  muscles  and  overlying  fascia  may  be 
exposed  for  suturing,  the  fibrinous  ring  must  be  dissected  away  in 
strips  by  means  of  scissors,  and  when  removed  the  hernial  opening  will 
be  found  much  enlarged. 


Fig.  627 


Lines  of  incision  in  the  abdominal  wall. 


After  the  dissection  of  the  scar  tissue  the  margins  of  the  hernial 
opening  will  be  found  to  be  the  structures  which  make  up  the  abdominal 
wall  at  this  point,  and  they  are  approximated  layer  by  layer  T\-ith 
sutures  as  follows: 

The  peritoneum  is  closed  in  a  vertical  direction  by  a  running  catgut 
suture.  Next  mattress  sutures  of  silk  or  linen  are  placed  so  as  to  include 
the  recti  muscles  and  overlying  fascia.  This  secures  an  overlapping 
of  the  fascial  structures.  The  overlying  structures,  subcutaneous  fascia, 
fat,  and  skin  are  closed  by  interrupted  catgut  sutures.  The  patient 
should  be  confined  to  her  bed  for  fourteen  to  sixteen  days,  during 
which  time  the  abdomen  is  well  supported  with  adhesive  straps.    An 


916 


COMPLICATIONS  FOLLOWING  OPERATIONS 


abdominal  binder  should  be  worn  for  several  months  following  the 
operation. 

Postoperative  Hematemesis. — Hemorrhages  from  the  stomach  may 
follow  upon  ligation  and  resection  of  the  omentum. 


Fia.  628 


Showing  operation  for  hernia.     Dovetailing  rectus  between  the  broad  abdominal  muscles. 

(KeUy-Noble.) 


Friedrich  and  Hoffmann  concluded  from  animal  experiments  that 
such  hemorrhages  were  often  the  result  of  the  dislodgement  of  thrombi 
in  the  omentum  and  their  lodgement  as  emboli  in  the  vessels  of  the 
walls  of  the  stomach. 

It  has  been  observed  that  hemorrhages  from  the  stomach  are  more 
liable  to  follow  chloroform  anesthesia,  and  the  explanation  is  given  that 


POSTOPERATIVE  NEUROSES  917 

chloroform  has  a  destructive  effect  upon  the  red  corpuscles;  this,  how- 
ever, would  appear  doubtful,  because  in  the  experiments  of  Friedrich 
and  Hoffmann,  the  emboli  found  in  the  walls  of  the  stomach  after 
operations  upon  the  omentum  occurred  just  as  frequently  when  no 
anesthetic  was  administered. 

Retention  and  Suppression  of  the  Urine.— In  all  abdominal  operations 
the  amount  of  urine  secreted  is  more  or  less  diminished.  No  anxiety 
need  be  entertained  unless  the  amount  falls  below  10  ounces  in  twenty- 
four  hours,  or  when  evidences  of  nephritis  are  found  in  the  urine. 
By  the  end  of  the  first  week,  and  certainly  not  later  than  the  twentieth 
day,  the  amount  of  urine  secreted  should  be  normal.  When  the  amount 
secreted  falls  below  10  ounces  in  twenty-four  hours,  or  persists  below 
the  normal  quantity  an  undue  length  of  time,  there  is  a  suspicion  of  the 
existence  of  some  affection  of  the  kidney  or  of  some  interference  with 
the  flow  of  urine,  as  from  the  accidental  ligation  or  wounding  of  the  ureter. 

Pain  in  the  region  of  the  kidney,  with  possible  enlargement  of  the 
organ,  is  additional  evidence  of  an  obstructed  ureter. 

The  constant  or  intermittent  dribbling  of  urine  into  the  vagina 
following  a  vaginal  section  needs  careful  investigation,  in  view  of 
finding  a  possible  vesicovaginal  or  uretero vaginal  fistula. 

The  amount  of  urine  is  materially  increased  by  the  injection  of 
quantities  of  salt  solution  into  the  bowel  shortly  after  operation,  or 
into  the  abdominal  cavity  after  the  completion  of  the  operation  and 
before  the  peritoneum  is  completely  closed. 

For  some  time  the  author  has  practised  as  a  routine  measure  in  all 
major  operations  the  injection  of  a  pint  of  normal  salt  solution,  and 
2  ounces  of  whisky  into  the  bowel  immediately  after  operation.  This 
injection  without  whisky  may  be  repeated  every  four  to  six  hours, 
until  the  amount  of  urine  secreted  is  not  less  than  20  ounces  in 
twenty-four  hours. 

Postoperative  Neuroses. — After  operations  there  may  develop  one 
of  the  several  forms  of  neuroses,  notably  hysteria,  neurasthenia,  melan- 
cholia, and  insanity.  It  is  probable  that  in  all  these  cases  the  individual 
is  endowed  with  an  unstable  mentality. 

Hysteria. — ^The  danger  lies  in  a  false  interpretation  of  symptoins 
whereby  grave  conditions  are  mistaken  for  hysteria.  Hysteria,  in 
itself,  is  a  troublesome  though  not  dangerous  condition;  it  is  a  psychic 
disease,  and  therefore  demands  psychic  treatment. 

Neurasthenia. — Here,  again,  we  encounter  a  psychic  disease  requiring 
psychic  treatment.  This  condition  commonly  ensues  when  the  uterus 
or  ovaries  have  been  removed,  and  may  persist  for  an  indefinite  time. 
Other  predisposing  causes  are  anxiety,  overwork,  exhaustion,  suppura- 
tion, and  anemia. 

Insanity.— It  has  not  been  conclusively  demonstrated  that  insanity 
follows  upon  gynecological  procediu-es  with  greater  frequency  than 
upon  those  in  general  surgery.  Yet  it  must  be  admitted  that  the  fre- 
quency with  which  it  follows  upon  gynecological  operations  suggests 
the  importance  of  its  consideration. 


918  COMPLICATIONS  FOLLOWING  OPERATIONS 

Kelly  estimates  that  it  has  occurred  in  about  0.5  per  cent,  of  his 
abdominal  cases,  and  in  about  the  same  ratio  in  his  plastic  work  on 
the  pelvic  floor.  Indeed,  it  would  appear  that  insanity  more  often 
follows  upon  minor  than  upon  major  operations,  and  may  follow  the 
administration  of  an  anesthetic  without  operation. 

The  author  has  seen  but  one  case  of  abdominal  section,  in  which  the 
patient  suffered  from  long-standing  melancholy,  which  deepened  into 
insanity,  and  led  to  suicide  in  the  fourth  week  of  convalescence. 

Insanity  may  follow  the  induction  of  the  menopause  by  the  removal 
of  the  ovaries,  or  may  be  excited  by  fear,  anxiety,  suffering,  suppura- 
tion, loss  of  blood,  drug  intoxication,  nephritis,  or  exhaustion.  It  may 
be  asserted  that  in  all  cases  the  individual  is  a  neurotic  to  begin  with; 
if  she  were  not  so  the  above-named  predisposing  factors  could  not  bring 
her  to  the  state  of  insanity. 

It  is  said  that  fully  one-half  of  these  cases  recover  control  of  the 
mind  within  one  to  six  months. 

No  suggestions  are  here  offered  as  regards  treatment  of  these  cases 
beyond  the  advice  to  guard  them  carefully.  These  are  cases  for  the 
alienist. 

The  popular  impression  that  the  removal  of  the  ovaries  particularly 
predisposes  to  insanity  has  no  foundation  in  fact.  Neurotic,  hysterical, 
and  melancholic  women  are  prone  to  become  insane,  and  the  same 
may  be  said  of  those  who  have  previously  been  insane. 

While  the  insanity  may  remain  permanent,  as  it  occasionally  does, 
it  is  to  be  expected  that  the  patient  will  gradually  improve  and  relief 
be  complete  in  a  relatively  short  time. 

Le  Roy  Broun,  after  reviewing  his  own  experience  and  that  of  others 
in  operations  upon  pelvic  diseases  in  insane  women,  says:^  "We  regard 
these  patients  as  having  a  right  to  be  relieved  of  their  physical  suffering, 
and  when  such  relief  can  be  given  through  surgery,  it  is  the  desire  in 
the  Manhattan  State  Hospital  that  such  will  be  afforded  them. 

"It  is  in  this  spirit  that  such  operations  have  been  done.  With  the 
physical  improvement  resulting,  some  of  the  patients  have  gone  on 
under  the  regular  hospital  treatment  to  a  complete  mental  recovery. 

"One  such  cure  of  the  patient's  mental  disturbance  is  more  than  a 
balance  against  many  failures.  This  is  especially  true,  since  in  no 
instance  in  the  experience  of  Manton,  of  Picque,  and  myself  has  the 
mental  state  of  any  patient  been  injured  by  the  operation  itself." 

To  operate  for  the  relief  of  insanity  is  a  hazardous  procedure  and  one 
that  is  never  justified.  It  is  the  lesion  in  the  pelvis  which  alone  should 
constitute  the  indication  for  operation,  and  having  such  an  indication 
in  the  insane,  the  surgeon  may  proceed  in  the  hope  that  improvement  in 
the  mental  condition  may  follow. 

Tympanitis. — This  is  one  of  the  most  distressing  of  the  complications 
following  abdominal  operations.  Tympanitis  occurs  most  frequently 
in  women  with  thin,  relaxed  abdominal  walls.    In  the  majority  of  cases 

1  Trans.  Amer.  Gyn.  Soc,  1905. 


TYMPANITIS 

Fig.  629 


919 


Hot  cloths  are  prepared  for  application  to  the  abdomen. 


Fig.  630 


Application  of  hot  fomentations  to  the  abdomen  for  relief  from  gas  pains.     Abdominal  dressing  is 

protected  by  oil  silk. 


920  COMPLICATIONS  FOLLOWING  OPERATIONS 

it  does  not  denote  a  serious  pathological  condition,  but  may  be  regarded 
merely  as  a  symptom.  When  extreme  the  respirations  and  heart 
action  are  embarrassed  and  there  is  much  suffering. 

Much  can  be  done  to  prevent  overdistention  of  the  abdomen.  The 
bowels  should  be  thoroughly  evacuated  before  operation,  they  should 
be  handled  as  little  as  possible  in  the  operation,  and  after  the  opera- 
tion, unless  contra-indicated,  they  should  not  be  opened  within  seventy- 
two  hours.  The  Fowler  position  will  aid  in  the  expulsion  of  gas.  When 
the  abdomen  is  thin  and  relaxed  it  should  be  well  supported  with 
adhesive  straps  and  binder. 

For  the  relief  of  gas  distention  the  author  gives  hypodermic  injections 
of  eserin  in  -^  grain  doses  as  required.  The  rectal  tube  is  inserted  at 
intervals  or  left  permanently  in  place.  Enemata  of  salts  §  j,  turpentine 
5j,  and  sweet  oil  §iij,  or  of  equal  parts  of  warm  milk  and  molasses, 
may  be  effectual  in  bringing  away  the  gas.  Hot  turpentine  stupes 
are  applied  to  the  abdomen.  Hoffmann's  anodyne,  in  doses  of  20 
minims  to  1  dram,  given  by  the  stomach,  will  often  afford  relief. 

Kelly  recommends  the  light  application  of  the  Paquelin  cautery 
to  the  tips  of  the  hairs,  without  actually  coming  in  contact  with  the 
skin. 

John  G.  Clark  reports  the  adoption  of  the  plan  of  inactivity  for  the 
first  four  or  five  days  in  the  management  of  the  bowels.  On  the  fourth 
or  fifth  days,  if  the  bowels  have  not  moved  spontaneously,  an  enema 
is  given.  He  says  that,  as  a  rule,  his  patients  are  comfortable  and  are 
seldom  troubled  with  gas.  The  author's  experience  is  in  accord  with 
that  of  Clark. 

Phlebitis. — A  not  infrequent  postoperative  complication  is  thrombo- 
phlebitis. It  occurs  about  once  in  150  abdominal  operations  on  the 
pelvic  organs,  and  is  most  often  seen  in  cases  of  pelvic  inflammation, 
carcinoma  of  the  cervix,  fibroids  of  the  uterus,  and  ovarian  tumors. 

The  femoral  vein  is  most  often  involved.  In  the  majority  of  cases 
but  one  side  is  involved;  possibly  the  left  more  often  than  the  right. 
When  both  legs  are  involved  it  is  assumed  that  the  thrombus  has 
involved  the  common  iliac  vein. 

As  predisposing  factors  anemia  is  of  prime  importance.  The  author 
once  observed  the  pressure  of  a  long  abdominal  retractor  upon  the 
left  femoral  vein,  and  within  two  days  symptoms  of  thrombophlebitis 
were  manifest  in  that  side.  Infection  is  also  a  prominent  causal  factor, 
as  is  pressure  from  pelvic  tumors. 

The  symptoms  pointing  to  thrombosis  of  the  pelvic  veins,  but  not 
involving  the  femoral  veins,  are  too  indefinite  to  permit  of  more  than 
a  conjecture.  There  may  be  pelvic  pain  associated  with  rise  of  tem- 
perature and  pulse-rate,  with  possibly  evidence  of  pulmonary  embolism. 

When  the  femoral  vein  is  thrombosed  the  diagnosis  is  not  difficult  to 
make.  At  the  onset  the  temperature  usually  rises  from  2°  to  4°,  and 
the  pulse  is  relatively  rapid.  Preceding  the  rise  of  temperature  there  is 
more  or  less  severe  pain  in  the  groin,  which  extends  a  variable  distance 
along  the  course  of  the  femoral  vein.    Early  in  the  course  of  the  affection 


VOMITING  921 

there  is  a  variable  degree  of  swelling  of  the  leg,  and  this  may  extend 
to  the  thigh.  The  course  of  the  vein  may  be  traced  by  a  livid  blue 
line  and  by  its  tenderness  and  sharp  outline  on  palpation.  These 
symptoms  continue  a  variable  time  and  then  quickly  or  slowly  recede. 
Serious  consequences  may  result  from  a  dislodgement  of  the  clot,  with 
embolic  infarctions  in  the  lungs  or  elsewhere.  This  is  the  more  serious 
if  the  thrombus  is  septic.  Absorption  of  the  thrombus  may  be 
slow,  in  which  event  the  limb  will  persist  in  its  swollen,  painful  con- 
dition for  weeks  or  months.  It  is  rare  that  the  condition  remains 
permanent. 

The  treatment  is  directed  toward  the  absorption  of  the  clot  and  the 
prevention  of  embolism.  The  patient  should  remain  in  the  recumbent 
position  for  two  weeks  after  the  temperature  has  subsided  to  normal, 
the  leg  is  elevated  on  pillows  to  an  angle  of  about  30  degrees,  the  Hmb 
is  loosely  wrapped  in  cotton,  and  all  massage  interdicted.  After  the 
expiration  of  several  weeks  gentle  massage  should  be  practised.  At 
the  onset  of  the  affection  ice-bags  may  be  placed  along  the  course  of 
the  vein,  and  lotions  of  lead  water  and  laudanum  applied  twice  daily, 
but  without  rubbing. 

Acute  Dilatation  of  the  Stomach. — This  is  a  more  frequent  compli- 
cation than  is  generally  known. 

Nothing  definite  is  known  as  to  the  cause.  Postoperative  adhesions 
may  obstruct  the  pyloris  and  induce  distention  of  the  stomach.  Com- 
pression from  tampons  and  drainage  tubes  may  so  compress  the  pyloris 
as  to  bring  about  distention  of  the  stomach.  It  is  observed  that  in 
cases  in  which  the  stomach  is  in  a  state  of  chronic  distention  or  inflam- 
mation further  distention  is  more  liable  to  occur. 

When  no  adhesions  or  evident  cause  of  compression  exist  one  is 
forced  to  accept  the  theory  of  paralysis  of  the  stomach. 

In  acute  dilatation  of  the  stomach  there  is  vomiting  of  large  quantities 
of  fluid,  distention  of  the  stomach  with  gas,  and  collapse.  The  breathing 
is  shallow,  rapid,  and  labored;  the  pulse  is  feeble  and  rapid;  the  tem- 
perature is  not  elevated,  and  may  become  subnormal;  peristalsis  is 
lacking,  and  there  is  no  difSculty  experienced  in  outlining  the  distended 
stomach  unless  the  bowel  is  likewise  distended. 

Treatment. — The  treatment  is  at  best  uncertain.  Atropine,  strychnine, 
and  eserine  may  be  given  hypodermically.  The  stomach  should  be 
washed  out  early  and  at  frequent  intervals.  Nourishing  enemata  may 
be  given  until  food  can  be  digested  by  the  stomach.  Some  good  may 
come  from  elevating  the  hips. 

When  there  is  a  possible  cause  for  compression  or  constriction  of 
the  pylorus  an  exploratory  incision  may  be  called  for. 

Vomiting. — It  is  rare  that  some  degree  of  nausea  and  vomiting  does 
not  follow  upon  operations  when  a  general  anesthetic  is  used.  The 
patient  may  have  an  idiosyncrasy  to  account  for  the  vomiting.  Neurotic 
individuals  are  particularly  susceptible. 

Diseases  of  the  digestive  tract,  such  as  chronic  gastritis,  gastric 
ulcer,  pyloric  obstruction,  and  intestinal  obstruction  are  underlying 


922  COMPLICATIONS  FOLLOWING  OPERATIONS 

factors.  Acute  peritonitis  or  adhesive  bands  in  the  peritoneal  cavity 
are  also  to  be  mentioned.  It  is  observed  that  vomiting  is  more  often 
excessive  "when  the  stomach  and  bowels  have  not  been  properly  emptied 
prior. to  operation.  The  effect  of  the  anesthetic  is  upon  the  vomiting 
centre  and  upon  the  mucosa  of  the  stomach  from  the  saturated  mucus 
which  is  swallowed. 

Persistent  and  violent  vomiting  becomes  a  serious  complication,  and 
is  indicative  of  grave  complications,  notably  of  ileus,  dilatation  of  the 
stomach,  peritonitis,  and  nephritis. 

Management  of  Persistent  Vomiting. — 1.  Elevation  of  the  patient  in 
the  Fowler  position. 

2.  "Withholding  all  food  by  the  stomach. 

3.  Hot-water  bottle  or  mustard  plaster  applied  to  the  epigastrium. 

4.  Stomach  lavage. 

5.  H\^odermic  injections  of  small  doses  of  morphine  (|  grain).  It 
must  be  borne  in  mind  that  morphine  will  occasionally  cause 
vomiting. 

Postoperative  Cystitis. — Taussig  has  made  a  careful  report^  on 
postoperative  cystitis,  of  which  the  following  is  an  abstract:  "Two 
main  factors  are  involved  in  the  causation  of  this  complication;  the 
first  is  truma,  the  second  infection."  A  third  factor  is  mentioned, 
that  of  retention,  which,  as  Taussig  says,  is  not  an  immediate  cause, 
inasmuch  as  such  cases  result  in  cystitis  through  the  above-named 
factors  from  the  use  of  the  catheter. 

Traumatism  of  the  bladder,  either  directly  inflicted  or  by  stripping 
the  bladder  from  the  uterus  or  ligating  bloodvessels  which  lead  to  the 
uterus,  are  potent  factors  in  the  development  of  postoperative  cystitis. 
In  Wertheim's  radical  abdominal  operation  for  cancer  of  the  uterus 
where  trauma  of  the  bladder  is  extreme,  cystitis  developed  in  64  per 
cent,  of  the  cases  of  Taussig.  This  in  contrast  with  vaginal  hj'ster- 
ectomy,  in  which  but  2  per  cent,  of  the  cases  suffered  postoperative 
cystitis. 

Infection  may  exist  prior  to  the  operation;  it  may  be  introduced 
at  the  time  of  operation  or  subsequent  to  the  operation. 

S-pontaneous  infection  through  the  urethra,  or  by  way  of  the  blood 
and  lymph  streams,  is  possible,  though  its  proof  is  not  conclusive. 
Unquestionably  microorganisms  of  low  vitality  existing  in  the  urethra 
may  find  their  way  to  the  bladder,  the  resistance  of  whose  tissues  is 
greatly  lowered,  and  thereby  permits  of  pronounced  infection. 

The  disinfection  of  the  urethra  is  impossible,  hence  the  passage  of 
catheter  and  sounds  endangers  the  bladder. 

The  jirevention  of  postoperaiive  cystitis  is  under  our  control  only  to 
a  certain  degree,  since  it  is  not  always  possible,  in  operating,  to  pre- 
vent injury  to  the  bladder,  and  the  use  of  the  catheter  is  often  impera- 
tive, hence  the  impossibility  of  altogether  avoiding  infection  of  the 
bladder. 

^  Surger\',  Gynecology,  and  Obstetrics,  Februar}',  1906. 


POSTOPERATIVE  CYSTITIS  923 

The  prevention  of  the  retention  of  urine  cannot  be  said  to  be  wholly 
under  the  control  of  the  surgeon,  though  numerous  means  are  at  our 
command,  all  of  which  have  merit. 

Werth  greatly  reduced  the  percentage  of  his  cases  of  retention  of 
urine  following  operation  by  filling  the  bladder  with  normal  salt  solution. 
Before  adopting  this  practice  his  percentage  was  55,  afterward  it  was 
reduced  to  9.7,  and  postoperative  cystitis  was  reduced  in  frequency 
from  11  to  2.9  per  cent. 

Baisch  recommends  the  injection  of  20  c.c.  of  a  2  per  cent,  boro- 
glycerin  solution  into  the  bladder  and  claims  universal  success  in  the 
naethod,  though  Frankenstein  claims  to  have  failed  in  50  per  cent,  of 
his  cases  in  which  this  method  was  tried. 

Unquestionably  the  sitting  posture  greatly  facilitates  the  act  of 
urination,  and  should  be  enforced  whenever  there  is  retention,  provided 
the  condition  of  the  patient  will  permit. 

The  retention  catheter  should  not  be  employed  except  in  exceptional 
cases,  such  as  following  operations  upon  urinary  fistulse. 

The  author  has  employed,  with  a  large  degree  of  success,  the  injection 
of  2  drops  of  spirits  of  camphor  into  the  urethra,  using  a  sterile  medicine 
dropper.  No  pain  is  caused  by  the  injection  if  the  solution  does  not 
come  in  contact  with  the  vulvar  surface.  The  urine  will  usually  be 
voided  within  three  minutes  following  the  injection. 

Trauma  is  produced  by  rough  handling  of  the  bladder  in  pelvic 
operations,  hence  the  necessity  of  avoiding  all  possible  injury  to  the 
bladder,  which  might  lead  to  cystitis  and  retention  of  urine.  All 
raw  surfaces  created  on  the  bladder  should  be  carefully  covered  with 
peritoneum  so  far  as  possible. 

Infection  should  be  prevented  by  exercising  every  possible  precaution 
in  the  sterilizing  of  catheters,  hands,  and  field  of  operation.  With 
every  possible  precaution  exercised  there  is  still  the  possibility  of 
infection  produced  by  the  passage  of  a  sterile  catheter  through  the 
urethra,  which  at  all  times  contains  microorganisms.  Hence  the  advis- 
ability of  restricting  the  use  of  the  catheter  by  encouraging  spontaneous 
evacuations  of  the  bladder. 

After  the  germs  have  gained  entrance  to  the  bladder  it  may  still 
be  possible  to  make  way  with  them  before  they  have  produced  an 
inflammatory  reaction.  A  certain  degree  of  antiseptic  quality  is  given 
the  urine  by  the  internal  administration  of  5  to  7  grains  of  urotropin, 
four  times  daily,  until  the  urine  becomes  acid  in  reaction.  Only  mild 
forms  of  infection  are  controlled  by  such  medication;  severe  forms  are 
little  or  not  at  all  aft'ected. 

The  irrigation  of  the  bladder  with  a  3  per  cent,  boric  acid  solution, 
if  frequently  repeated  and  long  continued,  will  give  good  results, 
though  not  all  operators  have  been  so  successful  as  has  Baisch,  who 
introduced  the  method.  Taussig  recommends  its  use  as  the  best  of 
prophylactic  measures.  After  the  development  of  a  severe  tA-pe  of 
cystitis  which  does  not  yield  to  bladder  irrigations,  a  justifiable  pro- 
cedure would  be  to  establish  an  artificial  vesicovaginal  fistula,  to  leave 


924 


COMPLICATIONS  FOLLOWING  OPERATIONS 


it  open  until  the  inflammatory  changes  in  the  bladder  have  disappeared, 
then  to  close  it. 

Acute  Nephritis. — Gynecological  operations  are  seldom  followed  by 
acute  nephritis  unless  there  has  been  a  preexisting  lesion  in  the  kidney, 
infection,  or  intestinal  obstruction.  In  ether  anesthesia  there  is  always 
the  danger  of  acute  nephritis. 


Fig.   631 


Vulvar  douche. 


The  condition  may  be  overlooked.  Persistent  nausea  and  vomiting, 
headaches,  defective  eyesight,  delirium,  stupor,  and  convulsions,  all 
suggest  the  possible  involvement  of  the  kidney,  and  should  call  for  a 
urinalysis. 

The  fact  that  the  lesion  may  exist  for  a  time  without  classical  mani- 
festations makes  it  imperative  that  the  urine  be  examined  daily  after 
operation  for  the  first  week  or  ten  days. 

The  treatment  does  not  differ  from  that  laid  down  in  text-books 
on  internal  medicine  for  acute  nephritis  iti  general. 

Traumatic  Fistulae. — Ureteral,  vesical,  and  rectal  fistulse  may  be 
the  direct  or  indirect  result  of  operations  upon  the  organs  themselves 
or  upon  neighboring  organs. 


POISONING  BY  DRUGS  925 

Ureteral  Fistulas  may  result  from  the  cutting,  ligating,  or  crushing  of 
the  ureter,  or  from  the  destruction  of  the  periureteral  circulation.  The 
accident  is  especially  liable  to  occur  in  the  course  of  hysterectomy 
and  the  removal  of  broad  ligament  cysts  and  fibroids.  (For  a  more 
detailed  account  of  ureteral  fistulse  see  pages  806  and  821.) 

Vesical  Fistulse. — We  find  the  same  causes  for  fistula  of  the  bladder 
as  for  the  ureter.  In  the  majority  of  cases  the  bladder  has  been  wounded 
in  the  course  of  a  vaginal  hysterectomy.  Formerly,  when  clamps  were 
used  in  this  operation,  the  accident  occasionally  occurred  from  pressure 
necrosis.  It  happens,  though  rarely,  that  a  vesical  fistula  develops 
from  the  opening  of  a  pelvic  abscess  into  the  bladder.  More  frequently 
ulcerative  processes  in  the  bladder,  either  cancerous  or  tuberculous, 
give  rise  to  fistulse.     (See  page  807.) 

Rectal  Fistulse. — The  author  has  seen  two  rectal  fistulse  caused  by 
direct  injury  in  the  performance  of  a  perineorrhaphy.  More  often  a 
cancerous  invasion  of  the  rectum  is  the  cause.    (See  page  804.) 

Pressure  Paralysis. — It  occasionally  happens  that  a  leg  may  be 
paralyzed  for  a  time  from  pressure  while  the  patient  is  in  the  lithotomy 
position.  Again,  the  shoulder  may  be  involved  as  the  result  of  pressure 
from  the  shoulder  supports  when  the  patient  is  in  the  Trendelenburg 
position. 

The  author  knows  of  no  case  of  permanent  paralysis,  but  has  seen 
a  number  of  cases  in  which  there  was  numbness,  tingling,  and  loss  of 
muscular  power  lasting  from  a  day  to  several  months. 

The  accident  is  preventable  by  seeing  to  it  that  no  undue  pressiu-e 
or  constriction  is  made  by  the  leg-holders  or  shoulder-braces. 

Burns. — This  is  a  distressing  accident,  not  only  to  the  patient  but 
to  surgeon,  nurse,  and  hospital  management.  The  accident  is  inexcus- 
able, in  that  it  can  be  prevented  if  due  care  and  diligence  be  exercised. 

The  hot-water  bottles  placed  about  the  patient  when  she  is  returned 
to  her  bed  should  rest  outside  the  blanket,  and  should  be  constantly 
guarded  from  coming  in  direct  contact  with  the  patient's  body. 

No  round  bottles  should  be  used,  because  they  are  liable  to  roll 
underneath  the  blanket. 

Emphysema  of  the  Abdominal  Walls. — On  two  occasions  the  author 
has  seen  a  wide  spreading  emphysema  of  the  abdominal  walls,  due  to 
infection  of  the  abdominal  wound  with  the  bacillus  aerogenes  capsulatus. 
Emphysema  of  a  less  significant  type  may  be  due  to  the  entrance  of 
air  into  the  tissues  about  the  incision. 

Poisoning  by  Drugs. — Opium  poisoning  has  been  occasionally  seen 
to  follow  operations  when  given  in  large  doses  by  mistake.  The  patient 
falls  into  a  deep  sleep,  the  respirations  are  greatly  slowed,  the  face 
cyanotic,  the  pupils  contracted,  and  the  throat  and  mouth  dry. 

Atropine  poisoning  gives  the  following  symptoms:  delirium,  restless- 
ness, dilated  pupils,  dryness  of  throat  and  mouth,  rapid  pulse  and 
respirations,  cutaneous  rash,  and  finally  stupor  and  coma. 

Mercury  poisoning  may  arise  from  the  administration  of  calomel, 
from  vaginal  douches,  and  the  irrigation  of  wounds.     The  secretion 


926  COMPLICATIONS  FOLLOWING  OPERATIONS 

of  saliva  is  increased,  the  gums  and  teeth  become  sore,  the  breath 
foul,  a  rash  appears  on  the  skin,  and  there  is  diarrhea. 

Iodoform  poisoning  may  arise  from  an  iodoform  gauze  pack  when 
placed  in  the  pelvis.  The  patient  becomes  uncomfortable,  is  restless 
and  depressed;  there  is  headache,  dizziness,  insomnia,  melancholia, 
and  delirium.  There  may  be  an  unpleasant  taste  in  the  mouth,  and 
the  urine  contains  iodine.  A  rash  may  appear  on  the  skin,  and  finally 
stupor  may  deepen  into  collapse. 

Carbolic  acid  should  not  be  employed  in  gynecological  practice. 

The  skin  eruptions  common  to  drug  poisoning  are  purpura,  lu'ticaria, 
eruptions  of  papules,  vesicles  and  pustules,  and  erythema.  The  drugs 
causing  these  eruptions  are  quinine,  copaiba,  arsenic,  mercury,  iodides, 
ergot,  belladonna,  opium,  bromides,  turpentine,  chloral,  carbolic  acid,  etc. 

Infectious  and  Contagious  Diseases. — Typlioid  fever  occasionally 
follows  upon  a  gynecological  operation.  The  author  has  had  one  such 
experience  after  removing  an  ovarian  cyst. 

Malaria  may  also  follow  upon  gynecological  operations.  The 
surgeon  must  not  be  hasty  in  arriving  at  the  conclusion  that  malaria  or 
tj^hoid  fever  is  present,  but  must  bear  in  mind  the  greater  possibility 
of  a  wound  infection. 

Diarrhea. — In  uremia  and  sepsis  diarrhea  is  a  not  uncommon  accom- 
paniment. More  often  improper  feeding  brings  on  a  gastro-enteritis. 
Diarrhea  associated  with  a  general  peritonitis  is  occasionally  observed. 
Poisoning  by  drugs,  notably  mercury,  will  explain  a  certain  number  of 
cases. 

So  far 'as  possible  the  cause  should  be  sought  and  removed.  The 
usual  remedies  may  be  given,  i.  e.,  bismuth,  opium,  etc. 

Bed-sores. — In  patients  greatl}^  debilitated  from  disease,  and  who 
are  confined  to  their  bed  for  a  long  period  of  time,  bed-sores  are  liable 
to  form,  and  the  utmost  care  must  be  exercised  in  preventing  their 
development. 

To  prevent  the  development  of  bed-sores  the  skin  of  the  patient 
must  be  kept  clean  and  dry.  She  must  be  shifted  from  one  position 
to  another,  and  the  bandages  must  be  applied  smoothly.  An  air-cushion 
will  aid  much  in  protecting  an  area  which  gives  the  appearance  of 
necrosis  of  the  soft  parts.  The  skin  may  be  toughened  by  frequent 
bathing  with  dilute  alcohol. 

When  the  ulcers  have  formed  they  are  to  be  kept  clean  by  frequent 
bathing  in  a  mild  antiseptic;  a  dusting  powder  of  bismuth,  calomel,  or 
boric  acid  should  be  used  freely,  and  the  ulcer  protected  by  a  dressing 
of  sterile  absorbent  cotton. 

Acid  Intoxication. — Little  definite  knowledge  is  obtainable  on  the 
subject  of  acid  intoxication.  We  know  of  its  presence  in  ,cases  of 
diabetes,  and  we  are  told  that  it  exists  in  carcinoma  and  anemia.  It 
may  exist  without  assignable  cause.  When  following  upon  operations 
the  following  symptoms  are  recorded  by  Miller:  Acetone  odor  to  the 
breath,  apathy,  distaste  for  food,  vomiting,  presence  of  acetone  and 
diacetic  acid  in  the  urine. 


EXCESSIVE  PAIN  927 

Ophthalmia.— Shortly  after  operation  an  ophthalmia  occasionally 
develops.  The  usual  cause  is  irritation  from  chloroform  or  ether. 
At  other  times  the  vomitus  may  infect  the  eye.  The  habit  of  trying 
the  pupil  reflex  by  touching  the  cornea  may  lead  to  injury  to  the  eye. 
A  cold  compress  should  be  placed  over  the  eyes  during  the  anesthetic. 
When  pus  is  present  no  time  should  be  lost  in  testing  for  the  presence 
of  gonococci. 

When  ophthalmia  develops  a  mild  astringent  should  be  applied  and 
the  eye  irrigated  with  a  boric  acid  solution. 

Late  Chloroform  and  Ether  Poisoning.— Similar  effects  to  phosphorus 
poisoning  have  been  observed  upon  the  liver,  heart,  and  kidney  cells 
as  a  late  result  of  chloroform  and  ether  anesthesia. .  Fatty  degeneration 
and  necrosis  are  the  usual  findings. 

Bevan  and  Favill  record  most  serious  effects  upon  the  liver.  The 
symptoms  caused  thereby  are  vomiting,  delirium,  coma,  convulsions, 
Cheyne-Stokes  respiration,  icterus,  cyanosis,  acetonemia,  and  acetonuria, 
and  finally  death  may  ensue.  The  onset  of  these  symptoms  may  be 
in  less  than  a  day  or  as  late  as  the  sixth  day. 

Irregularities  of  the  Pulse.— We  find  in  the  pulse  a  reliable  guide 
to  the  general  condition.  It  therefore  deserves  careful  observation 
during  the  critical  period  of  convalescence. 

Prior  to  the  operation  a  record  should  be  made,  not  alone  of  the 
pulse-rate,  but  of  the  quality  as  well,  for  the  purpose  of  comparison 
subsequent  to  operation,  otherwise  undue  alarm  may  be  occasioned  by 
an  irregular  heart  action  or  one  of  unusual  quality  when  observed  for  the 
first  time  after  operation,  not  knowing  that  such  was  the  condition 
prior  to  operation. 

The  rate  of  pulse  is  not  so  good  an  indication  as  the  volume  and 
rhythm.  An  increasing  pulse-rate  is  always  alarming,  and  particularly 
so  when  associated  with  a  decreasing  volume  and  irregularities  in  the 
rhythm.  The  nurse  may  take  the  pulse  at  a  time  when  the  patient  is 
disturbed  from  vomiting,  pain,  and  movements  of  the  bowels  without 
recording  the  incident,  thereby  leading  to  a  false  interpretation. 

Excessive  Pain.— What  is  pain  to  one  individual  may  not  be  pain 
to  another;  in  other  words,  there  is  a  great  variability  in  the  suscepti- 
bility to  pain  in  individuals.  We  must,  therefore,  have  regard  to  the 
psychic  element  in  our  cases. 

It  is  the  author's  practice  not  to  permit  the  suffering  of  great  pain 
following  operations  for  want  of  an  anodyne.  Distress  and  loss  of 
sleep  far  outweigh  the  harmful  effects  of  anodynes  judiciously  admin- 
istered. His  preference  is  for  heroin,  ^2  grain,  or  codeine,  y  grain  hyipo- 
dermically,  and  when  these  fail  the  sulphate  of  morphine,  I  to  f  grain, 
must  be  substituted.  The  effort  must  be  made  to  determine  the  cause 
of  the  pain  and  to  remove  it.  The  ice-bag  applied  over  the  seat  of  pain 
win  usually  serve  the  purpose.  Gas  pains  are  best  controlled  by 
elevating  the  body  of  the  patient  on  pillows,  by  the  administration  of 
eserin,  Jq  gram,  and  by  the  judicious  employment  of  enemata. 


928  COMPLICATIONS  FOLLOWING  OPERATIONS 

Variations  in  Body  Temperature. — As  with  the  pulse,  so  with  the 
temperature,  there  are  not  only  great  ^'a^iations  during  the  period  of 
convalescence  as  the  result  of  evident  causes,  but  such  variations  may 
occur  in  the  absence  of  a  demonstrable  cause.  Immediately  following 
a  prolonged  operation  the  temperature  may  drop  a  fraction  of  a  degree 
below  the  normal,  as  indeed  it  may  do  at  any  time  in  the  period  of 
convalescence.  On  the  other  hand,  beginning  with  a  few  hours  after 
operation  and  continuing  for  hours  and  possibly  days,  the  temperature 
may  rise  to  1°  or  2°  above  normal.  When  the  temperature  rises  more 
than  1°  above  the  normal  and  persists  for  two  or  more  days,  the  author 
believes  that  some  infection  exists,  whether  it  can  be  demonstrated  or 
not.  A  low  grade  of  infection  may  exist  in  the  peritoneal  cavity  or 
in  the  line  of  incision  without  giving  rise  to  local  manifestations. 

When  the  pulse  becomes  feeble  and  rapid  and  the  temperature  falls 
below  the  normal  one  is  liable  to  suspect  hemorrhage;  i^er  contra, 
when  the  pulse  increases  in  rate  and  volume  and  the  temperature  rises 
there  is  probability  of  infection. 

Secondary  Hemorrhage. — In  the  early  days  of  abdominal  surgery 
secondary  hemorrhage  was  a  not  uncommon  accident,  but  with  improved 
technic  there  is  little  liability  to  such  an  event. 

The  accident  is  liable  to  arise  when  a  defective  knot  is  made,  when 
too  much  tissue  is  incorporated  in  the  ligature,  when  the  ligature  is 
cut  too  close  to  the  knot,  when  raw  surfaces  are  left  uncovered  in  the 
pelvis  and  elsewhere,  and  when  infection  follows  quickly  upon  the 
operation. 

All  these  conditions  are  largely  eliminated  by  a  careful  surgeon, 
and  hence  secondary  hemorrhages  in  pelvic  operations  are  scarcely 
to  be  feared.  And  yet  the  accident  may  occur  in  the  hands  of  the  most 
painstaking  of  surgeons. 

Catgut  left  in  the  abdomen  may  soften  and  swell;  in  this  way  an 
ordinary  square  knot  may  be  loosened  and  give  way.  The  shrinking 
of  vascular  and  edematous  tissues  included  in  the  ligatures  loosens 
the  knot,  hence  the  rule  that  as  little  tissue  as  possible  should  be 
included  in  the  ligature. 

The  careful  covering  of  all  raw  surfaces  by  peritoneum  will  eliminate 
the  danger  of  capillary  oozing  when  adhesions  have  been  separated 
from  peritoneal  surfaces.  When  found  impossible  to  cover  such  raw 
surfaces  with  peritoneum  the  application  of  the  actual  cautery  at  a 
dull  glow  will  provide  an  acceptable  substitute. 

With  the  patient  in  the  Trendelenburg  position  all  bleeding  vessels 
and  oozing  surfaces  may  appear  controlled,  but  with  the  resumption  of 
the  horizontal  position  the  bleeding  may  start  afresh;  hence  the  rule 
that  in  cases  in  which  there  is  liability  to  hemorrhage,  the  incision  should 
not  be  closed  until  the  patient  is  placed  in  the  horizontal  position 
and  the  field  of  operation  carefully  inspected.  The  inspection  should 
be  so  deliberate  and  thorough  as  to  leave  no  possible  doubt  as  to  the 
security  of  the  hemostasis. 

In  dealing  with  large  bloodvessels  the  author  is  in  the  habit  of  using 


SECONDARY  HEMORRHAGE  929 

two  No.  2  plain  catgut  ligatures,  thus  providing  double  security.  A 
better  security  is  provided  by  the  use  of  silk,  or  linen  ligatures  to  large 
bloodvessels. 

^  Tissues  to  be  ligated  should  not  be  placed  on  the  stretch,  and  when 
ligating  close  to  a  clamp,  the  clamp  should  be  removed  as  the  knot  is 
tied.  ^        ^  ^, 

When  operating  in  the  presence  of  troublesome  capillary  oozing 
which  cannot  be  secured  by  ligatures,  time  will  be  saved  by  packing  a 
hot  sterile  pad  down  upon  the  oozing  surface.  This  may  be  left  until 
the  end  of  the  operation,  and  when  removed  the  oozing  will  usually  be 
found  to  be  controlled.  If  this  does  not  suffice  for  the  control  of  the 
oozing  blood,  a  transverse  incision  should  be  made  into  the  vagina  through 
the  cul-de-sac  and  the  end  of  a  long  strip  of  plain  or  iodoform  gauze 
passed  into  the  vagina,  and  the  remainder  of  the  strip  packed  into  the 
pelvis  and  made  to  firmly  press  upon  the  oozing  surfaces.  For  this 
purpose  the  author  uses  a  roll  of  gauze  made  of  four  plies,  five  inches 
wide  and  three  to  five  yards  long.  The  abdomen  can  then  be  closed 
with  sutures  and  two  to  four  days  later  the  gauze  is  removed  by  way 
of  the  vagina. 

When  it  is  impossible  or  hazardous  to  cut  into  the  vagina  from  above, 
a  Mikulicz  drain  may  be  substituted  and  brought  out  through  the  lower 
end  of  the  abdominal  incision. 

The  rapidity  with  which  symptoms  of  hemorrhage  present  depends 
directly  upon  the  amount  of  blood  lost  on  the  one  hand,  and  the  previous; 
condition  of  the  patient  on  the  other. 

There  need  be  little  fear  of  a  fatal  hemorrhage  from  an  oozing  surface; 
the  danger  is  that  the  escaped  blood  may  become  infected,  thereby 
creating  a  localized  abscess  and  subsequent  adhesions. 

Death  may  ensue  within  a  few  minutes  from  hemorrhage  when  the 
ovarian  or  uterine  arteries  are  not  secured  by  ligatures.  When  the 
bloodvessels  are  abnormally  large,  as  is  often  the  case  in  uterine  fibroids, 
double  ligatures  should  be  placed  about  the  largest  vessels. 

The  following  are  the  symptoms  suggestive  of  internal  hemorrhage: 

1.  Faintness  and  dizziness. 

2.  Restlessness. 

3.  Increasing  pallor. 

4.  Quickened,  sighing  respirations. 

5.  Increasingly  rapid  pulse  with  diminishing  volume. 

6.  Surface  of  body  cold  and  clammy. 

7.  Paroxysmal  abdominal  pain — may  be  severe. 

8.  Occasional  vomiting. 

9.  Increasing  dyspnea. 

10.  Dilated  pupils. 

11.  Unconsciousness. 

12.  Death  may  occur  in  from  a  few  minutes  to  forty-eight  hours. 
It  has  been  conclusively  shown  that  death  from  hemorrhage  is  not 

directly  due  to  the  total  loss  of  blood  but  to  the  lessened  volume  of 
blood  in  the  vessels  which  embarrasses  the  heart  action.    Herein  lies 
59 


930  COMPLICATIONS  FOLLOWING  OPERATIONS 

the  value  of  normal  salt  solution  as  a  remedial  agent  in  such  cases. 
By  adding  to  the  volume  of  the  blood  and  by  the  stimulating  influence 
of  the  sodium  chloride,  the  heart  is  stimulated  and  the  blood  tension 
is  increased.  In  view  of  the  heightened  blood  tension  produced  by 
normal  salt  solution  it  is  dangerous  to  employ  hj'podermoclysis  prior 
to  the  secm"ing  of  the  bloodvessels. 

\\h\]e.  it  is  to  be  desired  that  even^thing  shall  be  prepared  in  strict 
accord  ^vith  surgical  cleanliness,  it  must  be  borne  in  mind  that  the 
great  need  is  to  save  the  life  of  the  patient,  and  to  this  end  there  must 
be  no  delay  over  the  refinement  of  the  preparation.  A  hypodermic 
injection  of  morphine,  -g-  grain,  should  precede  the  h^-podermoc- 
lysis. 

If  possible  the  patient  should  be  taken  to  the  operating  room.  No 
anesthetic,  as  a  rule,  need  be  given,  and  at  most  only  enough  to  bewilder 
the  senses  of  the  patient  to  make  her  less  sensitive  to  pain. 

After  removing  the  stitches  and  exposing  the  pelvic  cavity  to  view 
by  means  of  retractors,  the  blood  is  carefully  but  hurriedly  removed 
by  sponges,  and  the  vessels  are  clamped  and  securely  ligated. 

The  abdomen  should  then  be  filled  with  sterile  normal  salt  solution 
at  a  temperature  of  110°  F.  The  abdomen  is  closed  with  through- 
and-through  silk  or  silkworm-gut  sutures.  If  any  doubt  exists  as  to 
the  control  of  bleeding-points  a  gauze  drain  should  be  inserted. 

Every  precaution  should  be  taken  to  prevent  further  shock.  The 
room  should  be  at  a  temperature  of  S0°  F.,  the  patient  wrapped  in 
warm  blankets,  a  hypodermic  of  -^  grain  of  strychnine  should  be 
given  before  leaving  the  operating  room,  and  if  no  salt  solution  has 
been  placed  in  the  abdomen,  a  pint  of  normal  salt  solution  and  two 
ounces  of  whisky  should  be  injected  into  the  bowel  while  the  patient 
is  yet  on  the  operating  table. 

\Mien  the  patient  has  been  returned  to  her  room  the  foot  of  the 
bed  should  be  elevated  eight  or  ten  inches,  hot-water  bottles  should 
be  placed  about  her;  she  must  be  -vsTapped  in  warm  blankets,  gV  grain 
strychnine  should  be  given  every  two  hours  during  the  period  of  great 
depression,  after  which  the  intervals  may  be  gradually  lengthened 
and  the  amount  decreased. 

"\Mien  there  is  extreme  depression  a  subcutaneous  injection  of  a 
pint  of  normal  salt  solution  should  be  given  three  or  four  times  in 
twenty-four  hours. 

Following  the  immediate  danger  from  hemorrhage  and  throughout 
the  period  of  convalescence,  every  possible  effort  should  be  made  to 
restore  the  quality  and  quantity  of  blood.  The  patient  should  be 
enjoined  to  rest  in  bed  and  to  take  the  maximum  amount  of  nourishment. 
Tonics  should  be  administered.  The  author's  preference  is  for  Blaud's 
pill,  grain  ij,  together  with  Fowler's  solution,  minims  iv  to  vij, 
given  after  meals.  General  massage  and  fresh  air  will  contribute  to 
the  upbuilding  of  the  patient. 

Foreign  Bodies  Left  in  the  Abdominal  Cavity  after  Operation. — It 
matters  not  how  confident  the  operator  may  feel  in  his  safeguards,  he 


FOREIGN  BODIES  LEFT  IN  THE  ABDOMINAL  CAVITY      931 

can  never  rid  himself  of  the  feeling  of  uncertainty  as  to  the  possibility 
of  leaving  a  sponge  or  an  instrument  in  the  abdominal  cavity. 

In  reviewing  the  literature  and  in  talking  with  surgeons,  one  is 
impressed  with  the  great  diversity  of  precautionary  measures,  and  yet 
it  is  doubtful  if  any  is  infallible. 

It  is  usually  in  the  difficult  cases,  requiring  a  great  number  of  sponges, 
that  the  accident  occurs,  and  it  is  in  just  such  cases  that  any  routine 
practice  may  miscarry.  - 

Fig.  632 


All  gauze  used  as  a  vaginal  pack  should  be  left  protruding  from  the  vulvar  outlet, 
prevent  the  leaving  of  gauze  in  the  vagina. 


This  will 


MacLaren  observes  that  in  these  later  days,  when  gauze  sponges 
have  replaced  sea  sponges,  the  mortality  of  these  cases  is  much  lessened. 
He  has  knowledge  of  ten  cases  where  sea  sponges  were  left  in  the 
abdominal  cavity,  and  in  nine  of  this  number,  death  ensued  from  general 
suppurative  peritonitis;  in  the  tenth  case  there  was  a  localized  abscess 
formation. 

It  is  of  interest  to  note  the  various  safeguards  adopted  by  surgeons. 
Colmann  recommends  that  the  compresses  have  a  tape  attached  to 
the  free  end  that  is  long  enough  to  tie  to  the  leg  of  the  operating-table, 
and  after  using  they  are  to  be  dropped  to  the  floor. 


932  COMPLICATIONS  FOLLOWING  OPERATIONS 

Fisher^  proposes  a  linen  tape,  three  or  four  feet  in  length,  armed  at 
one  end  with  a  needle,  by  which  the  compresses  are  transfixed  on  the 
tape.  A  piece  of  lead  weighing  a  half-pound  is  attached  to  each  pad 
to  prevent  the  pads  from  being  lost  among  the  coils  of  bowel. 

Gruzdew,  at  the  completion  of  the  operation,  irrigates  the  abdominal 
cavity  \dxh  sterile  normal  salt  solution,  and  then  passes  his  hand  over 
all  parts  of  the  ^'isce^a  in  search  for  sponges  and  instruments. 

Fritsch  sews  on  each  compress  a  long  black  thread  which  hangs  out 
of  the  wound  and  over  the  side  of  the  operating  table. 

Kruitchmann  marks  his  sponges  in  Roman  and  Arabic  numerals 
and  in  letters  as  follows:  I,  II,  III,  IV;  1,  2,  3,  -i;  a,  b,  c,  d.  After  using 
the  sponges  are  placed  on  the  floor  by  a  nurse  in  the  order  as  marked. 

^Mikulicz  attaches  a  long  thread  to  each  compress,  and  on  the  end 
of  the  tlu-ead  he  strings  a  glass  ball,  which  hangs  over  the  side  of  the 
operating  table. 

Rossel  attaches  to  each  compress  a  tape  20  cm.  long,  at  the  end  of 
which  is  a  sinker  weighing  three  grams. 

The  author's  method  is  as  follows:  Three  sizes  of  gauze  sponges  and 
compresses  are  used;  one  roll  five  yards  long  and  four  inches  vriAe  and 
six  plies  in  thickness;  second,  one  compress  one  yard  long,  eight  inches 
wide,  and  three  plies  in  thickness;  third,  tufts  of  gauze  so  made  as  to 
infold  all  edges  to  prevent  loose  threads  or  layers  of  gauze  from  rubbing 
off  on  the  viscera.  To  the  free  ends  of  the  rolls  and  compresses  is 
sewed  a  tape  twelve  inches  in  length,  and  to  this  tape  is  attached  an 
artery  clamp.  From  the  time  the  abdomen  is  opened  to  its  closure  no 
sponge  is  handed  the  operator  or  assistant  without  a  sponge-holder  in 
the  form  of  a  long  clamp. 

Before  sterilizing  the  roUs,  compresses,  and  sponges,  they  are  counted 
three  times  by  two  nurses,  then  wrapped  in  towels  and  the  number 
marked  on  the  wrapper  \\'ith  indelible  ink. 

Before  these  sponges  are  removed  from  their  "^Tappers  all  loose 
sponges  about  the  operating  room  are  removed.  The  sponges  and 
compresses  to  be  used  in  the  operation  are  then  counted  by  the  clean 
nurse  and  the  assistant.  This  count  is  made  separately  to  avoid  the 
possibility  of  error,  and  the  number  is  then  placed  on  a  slate.  If  addi- 
tional sponges  are  required  in  the  course  of  the  operation  they  are  to 
be  counted  and  added  to  the  number  on  the  slate. 

The  soiled  sponges  and  compresses  are  thrown  into  a  receptacle, 
from  which  they  are  taken  by  the  nurse  in  attendance  and  arranged 
in  parallel  rows  on  the  floor  in  order  that  the  count  may  be  facilitated 
at  the  close  of  the  operation.  T\Tiile  closing  the  peritoneum,  the  assistant 
and  clean  nurse  comit  the  sponges  and  compresses,  and  if  the  number 
corresponds  with  that  on  the  slate  the  wound  is  closed;  if  not,  search 
must  be  made  for  the  missing  sponge.  The  clamps,  forceps,  and 
scissors  are  also  counted  prior  to  the  opening  of  the  abdomen  and 
before  the  incision  is  closed. 

^  Annals  of  Surgery,  1908. 


FOREIGN  BODIES  LEFT  IN  THE  ABDOMINAL  CAVITY      933 

In  performing  abdominal  sections  in  private  homes,  where  it  is 
difficult  to  enforce  the  usual  safeguards,  the  author  has  adopted  the 
suggestion  of  Crossen  and  Wakefield  in  doing  away  with  all  loose 
sponges  and  small  pads  by  sewing  the  end  of  a  ten-yard  roll  of  gauze 
into  a  pocket  made  in  the  laparotomy  sheet  at  the  side  of  the  opening 
over  the  abdomen.  This  roll  of  gauze  serves  the  purpose  of  sponges 
and  pads  and  obviates  all  danger  of  leaving  the  gauze  in  the  abdominal 
cavity. 

The  question  may  arise,  How  can  we  prevent  litigation  in  such  cases? 
Unquestionably  the  prophylactic  measures  of  exercising  every  possible 
precaution  is  of  the  greatest  value.  For  the  operator  to  demand  a 
release  on  the  part  of  the  patient  before  operating  is  a  confession  of 
weakness,  and  has  no  practical  value. 

Kossmann  advocates  starting  a  counter-suit  for  libel  in  the  expectation 
that  the  prosecution  will  retract. 

Schauta  says  that  every  suit  brought  against  a  surgeon  for  the  leaving 
of  a  foreign  body  in  the  abdomen  is  equivalent  to  conviction,  because 
the  surgeon  is  discredited  in  the  eyes  of  the  public. 

Richardson  says  he  has  on  several  occasions  found  foreign  bodies 
in  the  abdomen  left  there  by  other  surgeons,  but  in  no  instance  has  the 
occurrence  been  made  known  to  the  detriment  of  the  operator. 

It  is  hoped  that  all  surgeons  will  be  equally  charitable,  if  for  no 
other  reason  than  that  we  are  all  liable  to  become  the  victims  of  this 
grievous   error. 


INDEX 


A 


Abdomex,  constriction  of,  237 
examination  of,  91 
exploratory  incision  of,  132 
ice  applications  to,  893 
operation  on,  preparation  for,  242 
pendulous,  59 

support  of,  by  corsets,  239,  244 
Abdominal  examinations,  91 
auscultation  in,  99 
inspection  in,  91 
mensuration  in,  99 
palpation  in,  93 
percussion  in,  97 
pad  applied  after  operation,  887 
support,  896 

in  cystocele,  293 
Abdominovaginal  examination,  107 

rectal  examination,  115 
Abortion,  in  retroversiofiexion,  357 

tubal,  152,  153 
Abscess,  Bartholinean,  401 

of  lungs,,  following  operations,  908 
of  ovary,  489,  761 
chronic,  483 

cystic  degeneration,  484 
.  of  pehns,  510-516 
in  tubal  pregnancy,  152 
of  uterus,  438 
Absence  of  Fallopian  tubes,  286 
of  ovaries,  286 
of  uterus,  276 
of  vagina,  270 
of  vulva,  260 
Accessary  ovary,   causing  menstruation, 

26 
Actinomycosis,  of  Fallopian  tubes.  466 
Adenocarcinoma,  uteri,  650 
Adenofibromyoma  uteri,  585 
peritoneal,  506 
of  prepuce,  265 
Adipocere,  154 
Adiposity,  associated  with  amenorrhea, 

39 
Alcoholism,  causing  sterihtj',  69 
Alexander  Adams'  operation,  378 
Allantoic  cyst  from  ovarian  tumors,  729 
Amenorrhea,  37 

absence    of    menstruation,    physio- 
logical, 37 
absolute,  37 
causes  of  general,  37 


Amenorrhea,  causes  of,  local,  39 
diagnosis  of,  40 
functional,  41 
infectious  diseases  and,  38 
menstrual  molimina  and,  40 
relative,  37 
treatment  of,  41 
temporary,  38 
vicarious  menstruation,  40 
without  apparent  cause,  39 
Ampullar  tubal  pregnane}^,  147 
Amputation  of  cervix,  298 
Martin's,  796 
Schroeder's,  795 
of  tubes,  478 

of  uterus  in  inversion,  344 
Amyloid  degeneration  of  uterine  fibroids, 

589 
Anatomy  of  bladder,  825 

of  cellular  tissue  of  pehas,  510 
of  Fallopian  tubes,  382 
of  hymen,  267 
of  menstruating  uterus,  24 
of  ovaries,  384 
of  ureters,  869 
of  urethra,  825 
of  uterus,  305 
of  vagina,  288 
of  ^nilva,  264 
Anemia,  83 

causing  sterility,  69 

uterine  hemorrhage,  27 
Anesthesia,  choice  of,  246 
general,  248 
local,  247 

resuscitation  in,  249 
signs  of,  248 
Anesthetizer,  248 
Angioma  ^nilvse,  393 
Anomalies  of  genital  organs,  262 
of  ovaries,  286 
of  tubes,  286 
of  uterus,  276 
of  vagina,  270 
of  vulva,  263 
Anteflexion  of  uterus,  347 
Anteposition  of  uterus,  309 
Anterior  colporrhaphy,  294 
Anteversion  of  uterus,  345 
Antitoxin  of  diphtheria,  227 
Appendicitis,  differentiated  from  ectopic 
pregnancy,  162 
from  sactosalpinx,  459 


936 


INDEX 


Arteriosclerosis  of  uterus,  cause  of  hemor- 
rhage, 30 
Arthritis,  cause  of  backache,  58 
Artificial  vagina,  272 
Ascites,  differentiated  from  ovarian  cyst, 

725 
Asepsis  in  gjTiecology,  principles  of,  252 
disinfection   of   hands   and 

forearms,  252 
operating  bag,  260 
preparation   of   gauze   and 
sutures,  255 
of  instruments,  256 
of  operating  room,  257 
in  home,  258 
of  surgical  utensils,  254 
sterilization  of  field  of  oper- 
ation, 244 
sterilized  water,  257 
Atony  of   uterine   supports,  massage  in, 

216 
Atrophy  of  fibroids  of  uterus,  587 
of  ovary,  550 
of  uterus,  549 
of  vagina,  549 
of  vulva,  546 
Atresia,  causing  amenorrhea,  39 
of  vagina,  272 
of  vulva,  262 
Auscultation  of  abdomen  in  extra-uterine 
pregnancy,  156 


B 


Backache,  56 
causes  of,  56 
arthritis,  58 
coccygodynia,  58 
traumatisms,  58 
uterine  disorders,  58 
mobility  of  sacro-iHac  joint  in,  57 
static,  57 
treatment  of,  58 
Bacteriological  examinations,  84 
of  Fallopian  tubes,  87 
of  normal  genital  tract,  84,  389 
of  ovary,  88 

of  pelvic  cellular  tissue,  89 
of  peritoneum,  89 
of  uterus,  86 
of  vagina,  85 
of  vulva,  85 
Bacteriology  of  normal  genital  tract,  84, 

389 
Bag,  hydrostatic,  414 

operating,  260 
Baldy  operation  for  prolapsus  uteri,  331 
Baldy- Webster  operation  on  round  Uga- 

ments,  371 
Bardeen  CO2  freezing  microtome,  95 
Bartholinean  glands,  abscess  of,  401,  402, 
521,  524 
anatomy  of,  402 
cancer  of,  564 
cysts  of,  401,  521,  524 


Bartholinean  glands,  gonorrhea  of,  521, 
524 
inflammation  of,  401,  402,  521, 
524 
Barthohnitis,  gonorrheal,  401,  521,  524 
Baths,  189 

duration  of,  190 
during  menstruation,  195 
position  of  patient  in,  190 
public,  230 

rest  and  friction  after,  190 
temperature  of,  190 
time  of  taking,  190 
varieties  of,  191 

cold  tub  bath,  194 
full  tub  bath,  193 
half  bath,  192 
Nauheim  bath,  195 
Russian  bath,  195 
sea  bath,  194 
shower,  191 
sitz  bath,  194 
Turkish  bath,  195 
Bathing  during  menstruation,  195 
therapeutics  of,  196 
Bicornate  uterus,  282 
Bilateral  tubal  pregnancy,  145 
Birth  of  uterine  fibroid,  593 
Bladder,  anatomy  of,  825 

cystoscopic  appearance,  833 
anomalies  of,  852 
calculus  of,  855 
catheterizing  of,  891 
curettage  of,  864 
cystoscopy,  830 

distended  from  ovarian  cyst,  723 
double,  853 

emptying  of,  after  operation,  891 
examination  of,  829 

digital,  830 
fissures  of,  852 
fistula  of,  807 
foreign  bodies  in,  855 
hemispheres  of,  828 
hernia  of,  855 
hyperemia  of,  864 
inflammations  of,  857 
inspection   of,    through    cystoscope, 

830 
landmarks  in,  833 
loculate.  853 
malpositions  of,  853 
physiology  of,  827 
topography  of,  827 
tuberculosis  of,  860 
tumors  of,  864 
Blasen  mole,  177 
Blind  pouches  of  vagina,  276 
Blood,  effect  of  uterine  fibroids  fin,  604 
examinations  of,  78,  242 
anemia,  83 
differential  count,  82 
leucocytosis,  80 

inflammatory,  81 
in  mahgnancy,  82 
morphology  of  blood  Cells,  79 


INDEX 


937 


Blood,  examinations  of,  leucocytosis,  in 
ovarian  tumors,  82 
posthemorrhagic,  80 
of  pregnancy,  80 
postpartum,  80 
red  cells,  78 
white  cells,  79 
normal,  78 
Body  of  uterus,  cancer  of,  638 
fibroids  of,  582 
sarcoma  of,  695 
Bowels,  care  of,  after  operation,  893 
Breaking  of  stitches,  911 
Broad  ligaments,  cancer  of,  699 
cysts  of,  718 
fibroids  of,  629,  699 
sarcoma  of,  69 
varicocele  of,  517 
Bronchitis  following  operations,  907 
Byrne  method  of  treatment  of  cancer  of 
cervix,  660 


Calculus  of  bladder,  855 

of  ureter,  881 
Cancer  of  Bartholinean  glands,  564 
of  broad  ligaments,  699 
of  Fallopian  tubes,  701 
of  ovarian  ligaments,  699 
of  ovaries,  712 
of  round  ligaments,  700 
of  urethra,  851 
of  uterus,  632 
acute,  640 
anatomy  of,  634 
associated  with  fibroid  tumors, 

633 
body  of,  treatment  of,  677 
cachexia  in,  641 
catheterizing     after     operation, 

892 
causing  hemorrhage,  29 
of  cervix,  634 

complicating  pregnancy, 

treatment  of,  676 
inoperable,    treatment     of, 
677 
chronic,  640 

complicating  pregnancy,  676 
diagnosis  of,  641 
clinical,  639 
differentia],  651 
extension  of,  655 
macroscopic,  641 
microscopic,  644 
etiology  of,  632 
extension     of,    to     surrounding 

parts,  647 
leucorrhea  in,  641 
pain  in,  641 
topographical    classification    of, 

632 
treatment  of,  660 

Byrne  method,  660 


Cancer  of  uterus,  treatment  of,  radical 
abdominal  operation,  665 
Schuchardt  operation,  662 
simple  vaginal  hysterec- 
tomy, 660 
a;-rays  in,  223 
of  vagina,  570 
of  vulva,  562 
Cancerous    degeneration    of    fibroids    of 
uterus,  591 
ulcers  of  cervix,  634 
Cantharides  plaster,  211 
Cardiopathy  in  uterine  fibroids,  602 
Caruncle,  urethral,  851 
Catarrh  of  cervix,  415 
Catarrhal  salpingitis,  447 
acute,  448 

anatomical  diagnosis  of,  448 
chronic,  448 
etiology  of,  447 
hydrosalpinx,  449 
salpingitis  isthmica  nodosa,  449 
vaginitis,  407 
vulvitis,  397 
Catching  cold,  cause  of  amenorrhea,  38 
Catheterization  of  bladder,  891 

of  ureters,  874 
Cauliflower  cancer  of  cervix,  634 
Celiotomy,  vaginal,  614 
Celloidin  sections,  137 
Cellulitis.    See  Pelvic  cellulitis,  510 
Cervical  endometritis,  415 
Cervix,  amputation  of,  298,  795 
anatomy  of,  305 
cancer  of,  634,  636 
catarrh  of,  415 

dilatation  of,  in  anteflexion,  349 
ectropion  of,  419 
erosions  of,  416 
fibroids  of,  583 
fistula  of,  818 

follicular  degeneration  of,  417 
hemorrhage  from,  23 
hypertrophy  of,  553 
inflammations  of,  415 
lacerations  of,  795 
sarcoma  of,  694 

technic  of  excising  piece  of,  for  exami- 
nation, 134 
tuberculosis  of,  420,  541 
ulcers  of,  420 

cancerous,  634,  644 
decubitus,  420 
tuberculous,  420,  541 
wounds  of,  793 
Change  in  environment  causing  amenor- 
rhea, 38 
Childbirths,  in  case  taking,  21 
Children,  gonorrhea  in,  536 
Chloroform  anesthesia,  250 
Chlorosis,  causing  amenorrhea,  41 
Chorioepithehoma  malignum,  174 

causing  uterine  hemorrhage,  29 
clinical  diagnosis  of,  175 
etiology  of,  174 
macroscopic  appearance  of,  176 


938 


IXDEX 


Chorioepithelioma  malignum,  malignant 
degeneration  of  hydatid  mole, 
177 
microscopic  appearance  of,  176 
primary,   outside  the  placental 
site,  182 
histogenesis 

of,  184 
diagnosis    of, 
185 
treatment  of,  186 
of  vagina,  574 
Circular  amputation  of  cervLx,  796 
Circulatory    disturbances    in    FaUopian 
tubes,  445 
causes  of,  445 
diagnosis  of,  anatomi- 
cal, 445 
clinical,  446 
treatment  of,  467 
in  ovary,  480 
in  pehi's,  causes  of.    See  Pelvic 

infections,  589 
of  %'ulva,  393 

edema,  396 
gangrene,  396 
hematoma,  395 
noma  pudendi,  397 
varicose  veins    ('angio- 
ma ^nilvse),  393 
Climacterium,    influence   on   fibroids    of 

uterus,  576 
Clitoris,  absence  of,  264 
adhesions  of,  265 
atrophy  of,  264 
cancer  of,  562 
hjTjertrophy  of,  264,  553 
CoccvgodATiia,  58 
Cold^ub  bath,  194 
Cohnheim"s  theory,  633 
Colpitis,  406 

Colpoperineorrhaphy,  763 
after-treatment  of,  788 
external  superficial  tear,  763 
internal  and  combined  tears,  765 
late  repair  of  complete  tear,  782 
relaxation  of  pelvic  floor,  786 
repair  of  sphincter  ani,  786 
Colporrhaphy,  763 

anterior,  294 
Combined  gj-necological  operations,  250 
Complications  following  operations,  897 
Conception,  condition  essential  to,  67 
Condyloma  acuminata,  411,  552 
Condj-lomatous  vaginitis,  409 
Congenital    absence    of    sexual    organs, 

causing  amenoiThea,  39 
Congestion,  pehic,  389 
Consanguinity,  causing  sterUity,  69 
Conservative  operations  on  ovaries,  753 
Constipation,  cause  of  circulatory  pelvic 

disorders,  391,  393 
Contracted   uterine   Ugaments,    massage 

m,  216 
Convalescence,  duration  of,  894 
Corpus  lutetun,  77 


Corpus  luteum,  abscess  of,  489 
cysts  of,  703 
extract  of,  228 
Corsets,  239 
Coimter-irritation,  211 

cantharides  plaster  in,  211 
mustard  plaster  in,  211 
Curet.    See  Uterine  curet. 
Cm-ettage,  126 

of  bladder,  864  _ 
in  chronic  metritis,  436 
in  diagnosis.  134 

in  inoperable  cancer  of  cervix,  677 
in  puerperal  infection,  436 
Cystadenoma  pseudomucosum,  708,  711 

serosirm,  708,  712 
Cystic  degeneration  of  ovaries,  30,484, 757 
of  uterine  fibroids,  590 
new  formations  of  Fallopian  tubes,  701 
Cystitis,  857 

following   operations   for    cancer    of 

cervix,  671 
gonorrheal,  524 
treatment  of,  861 
tuberculous,  860 
Cystocele,  388 

anatomj-  of,  288 
differential  diagnosis  of,  290 
etiology;  of,  288 
prognosis  of,  291 
symptoms  of,  299 
treatment  of,  291 
Cystoscopic  appearance  of  normal  blad- 
der, 833 
Cj-stoscopy,  830 

Cj-sts,     allantoic,     differentiated     from 
ovarian,  729 
of  Barthohnean  glands,  401,  421,  424 
of  bioad  ligaments,  718 
chylous,  differentiated  from  ovarian 

tumors.  729 
of  corpus  luteum,  703 
dermoid  of  Fallopian  tube,  701 
of  ovar}',  714 
of  ^tilva,  56  J 
echinococcus,  differentiated  from 

ovarian  cj'sts,  724 
of  Fallopian  tube,  702 
hj'datid  of  ^lorgagni,  703 
of  hj-men,  269,  56 
of  labia  minora,  559 
of  ovary,  703-714 

simple,  703 
pancreatic,  differentiated  from  ovar- 
ian cysts,  728 
parovarian,  718,  724 
tubo5varian,  703 
of  vagina,  567 
of  ^nilva,  560 

sebaceous,  559 


Debilitatixg  diseases  causing  amenor- 
rhea. 37 


INDEX 


939 


Decidua,  of  extra-uterine  pregnane}^,  142, 
655 
of  menstruation,  142 
of  uterine  pregnancy,  142 
Decidual  endometritis,  424 
Deciduoma  maUgnum,  174.    See  Chorio- 

epithelioma  malignum. 
Decubitus  ulcers  of  cervix,  651 

of  vagina,  573 
Degenerations  of  fibroids  of  uterus,  586 
amyloid,  589 
atrophy  of,  587 
calcareous,  588 
cancerous,  591 
cystic,  590 
fatty,  588 
gangrenous,  589 
m5rxomatous,  589 
sarcomatous,  591 
suppuration,  589 
telangiectatic,  589 
Delayed  menopause,  74 
Dermoid  cysts  of  FaUopian  tubes,  701 
of  ovary,  714 
of  vulva,  560 
Descensus  ovarii,  386 
uteri,  315 
vaginse,  317 
Development  of  genital  organs,  263 

of  uterus,  307 
Diastasis  recti,  59 
Diet,  general,  251 
liquid,  251 
soft,  251 
Digital  examination  of  bladder,  830 

of  internal  genitals,  100 
Dilatation  of  cervix  in  anteflexion,  349 

of  Tu-ethra,  844 
Diphtheritic  infection  of  vulva,  399,  400 
Disinfection  of  hands,  252 
Displacements  of  genital  organs,  288 

causes    of    circulatory    dis- 
turbances, 393 
of  pelvic  inflammation, 
393 
Displacements  of  FaUopian  tubes,  382 
ovaries,  384 
uterus,  305,  317 
vagina,  317 
Diverticula  of  Fallopian  tubes,  286 
Double  cervix,  286 
uterus,  286 
vagina,  275 
vulva,  262-263 
Douche  in  chronic  metritis,  439 
intra-uterine,  200 
vaginal,  196 
Drainage  of  pelvic  abscess,  516 

by  tampons,  214 
Dress,  237 

Dropsy  of  chorionic  viUi,  177 
Drinking  water,  208 
Drug  addiction,  causing  amenorrhea,  38 
Ductless  glands,  227 

disordered  functions  of,  39 
Dudley  operation  for  anteflexion,  351 


Dysmenorrhea,  41 
causes  of,  42 

conical  cervix,  56 
dilatation  of  cervix  in,  51 
membranous,  45 
nasal,  46 

ovariotomy  in,  54 
periodic  intermenstrual,  47 
primary,  42 

in  retroversioflexion,  357 
secondary,  43 
stem  pessaries  in,  54 
treatment  of,  45 

medical,  49 

surgical,  51 
Dyspareunia,  causing  sterility,  69 


E 


EcHiNococcus  cysts  from  ovarian  cysts,' 

724 
Ectopic    pregnancy,    143.      See    Extra- 
uterine pregnancy. 
Ectropion  of  cervix,  419 
Eczema,  .x-raj's  in  treatment  of,  224 
Edema  of  vulva,  396 
Electricity,  223 
Elephantiasis  vulvae,  551 
Elevatio  uteri,  313 
Embolism  in  fibroids  of  uterus,  604 

pulmonary,  902 

simulating   surgical   shock, 
899 
Emmet's  perineorrhaphy,  774 
Emphysema  vaginse,  408 
Endocervicitis,  415 

treatment  of,  442 
Enchonclroma  of  ovary,  716 

of  vulva,  559 
Endometritis,  cervicahs,  415 

classification  of,  anatomical,  425 

fungous,  426 

glandular,  427 

hypertrophic,  426 

interstitial,  431 

macroscopic,  426 

microscopic,  427 

polypoid,  426 

pseudodiphtheritic,  426 

ulcerative,  426 

\dUous,  426 
clinical,  421 

acute,  421 

catarrhal,  422 

cbTonic,  422 

decidual,  424 

dj'smenorrheic,  425 

exfohative,  140,  424 

gonorrheal,  423 

hemorrhagic,  422 

postabortive,  424 

puerperal,  424 

senile,  425 

tuberculous,  423 
curet  used  in,  126 


940 


INDEX 


Endometritis,  diagnosis  of  scrapings  in, 
427,  431 
treatment  of,  442 
uterine  hemorrhage  and,  28 
Endometrium,    myometrium,   tubes  and 

ovaries  in  uterine  fibroids,  591 
Endothelioma  of  ovary,  717 
of  uterus,  692 
of  vagina,  574 
Enteroclysis.  203 
Enteroptosis,  59 
Enterovaginal  fistula,  806 
Epispadias,  265 
Erosions  .of  cervix,  416 

differentiated  from  cancer,  651 
Erysipelatous  vulvitis,  398 
Eversion  of  cervix,  416 

differentiated  from  cancer,  651 
treatment  of,  444 
Examinations   of   external   and   internal 
genitalia,  100 
abdominovaginal,  107 
combined  vaginal,  106 
digital,     of     internal 
genitals,  100 
of  rectum,  112 
of  vagina,  100 
inspection  of   external 

genitals,  100 
palpation     of     ureters 
through  vagina,  112 
pelvimeter,  117 
physical,  90 

auscultation,  99 
inspection,  91 
mensuration,  99 
palpation,  93 
percussion,  97 
preliminary  measures,  90 
Exercise,  indoor,  230 
Exfoliative  endometritis,  140 
Expelled  membranes  from  uterus,  142 

decidua     of     extra-uterine 
pregnancy,  142 
of  menstruation,  142 
of   uterine   pregnancy, 
142 
diagnosis  of,  140 
examination    of,  macro- 
scopic, 141 
microscopic,  141 
exfoliative     endometritis 
(membranous  dysmenor- 
rhea), 140 
Exploratory    incisions    in    ectopic    preg- 
nancy, 158 
punctm-e  of  ectopic  pregnancy,  158 
and  incisions,  132 
Extended  vaginal  operation  for  cancer  of 

cervix,  662 
Extension  of  cancer  of  uterus,  655 
External  genitals,  inspection  of,  100 
Extra-uterine  pregnancy,  143 

anatomical  changes  in  tube,  154 
bilateral,  154 
classification  of,  146 


Extrauterine  pregnancy,  classification  of, 
ampullar,  147 
infimdibular,  150 
interstitial,  150 
ovarian,  151 
diagnosis  of,  clinical,  155 

objective  signs,  156 
subjective  signs,  156 
differential,  158 
ending  of  gestation,  152 
history  of,  155 
mortahty  of,  172 
recm-rent  and  multiple,  144 
retrogressive  changes  in,  154 
treatment  of,  164 

of  advanced  pregnancy,  170 
at  time  of  rupture,  165 
of   combined   extra-uterine 
and    tntra-uterine    preg- 
nancy, 171 
of    interstitial    pregnancy, 

170 
of    intraligamentary    preg- 
nancy, 170 
late  after  rupture,  167 
of  ovarian  pregnancy,  171 
in  rudimentary  horn,  170 
of  unruptured,  16 
Exudates,  parametric,  512 

differentiated    from    paratyph- 
htic,  515 
from  perimetric,  515 
from  peritoneal,  506 
from  psoas  abscess,  516 
from  salpingitis,  461 


Fallopian  tubes,  actinomycosis  of,  466 

anatomy  of,  382 

anatomical   changes  in   ectopic 
pregnancy,  154 

anomalies  of,  286 

bacteriology  of,  87 

carcinoma  of,  701 

circulatory  distm-bances  of,  445 

cystic  new  formations  of,  703 

dermoid  cyst  of,  701 

gonorrhea  of,  454,  459,  522,  526, 
534 

examination  of,  109 

infectious  granulomata  of,  446, 
462 

inflammations  of,  446 

lipoma  of,  701 

parasites  of,  466 

papilloma  of,  700 

polyps  of,  701 

sarcoma  of,  701 

syphilis  of,  466 

tumors  of,  700 

tuberculosis  of,  462,  478,  541 
Family  history,  in  case  taking,  21 
Fate  of  ovarian  tumors,  736 
Fatty  degeneration  of  uterine  fibroids,  588 


INDEX 


941 


Faulty  secretions,  contra-indications    to 

operation,  243 
Fecal  fistula,  801 

enterovaginal,  806 
rectolabial,  805 
rectoperitoneal,  804 
rectovaginal,  801 
Fermentation  fever  following  operations, 

909 
Fibroids  of  uterus,  575 

adenofibromyoma,  585 
amyloid  degeneration  of,  589 
associated  with  cancer,  633 
atrophy  of,  588 

calcareous  degeneration  of,  588 
cancerous  degeneration  of,  591 
cardiopathy  in,  602 
causing  uterine  hemorrhage,  29 
of  cervix,  583,  595 
in  climacterium,  576 
complicating  pregnancy,  630 
death  from,  604 
degenerations  of,  586 

cystic,  590 
differentiated  from  cancer,  652 
from  chronic  metritis,  597 
from    extra-uterine    preg- 
nancy, 161 
from  hematoma,  600 
from  ovarian  cysts,  721 
from  pelvic  exudates,  515 
from  pyosalpinx,  460 
from  retroversioflexion,  362 
from  uterine  pregnancy,  597 
effect  of,  on  blood,  604 

on  neighboring  organs,  604 
embolism  in,  604 
etiology,  575 

fatty  degeneration  of,  588 
gangrene  of,  589 
hemorrhage  in,  592,  600 
imperial  life,  600 
interstitial,  583,  594 
intestinal    obstruction    due    to, 

601 
latent,  584 
in  menstruation,  576 
myxomatous    degeneration    of, 

589 
in  pregnancy,  576,  600 
pressure  in,  592 
rate  of  growth  of,  592 
recurrence  of,  584 
sarcomatous    degeneration    of, 

591,  697 
septic  infection  of,  601 
submucous,  582,  595 
subserous,  594,  595 
suppiuation  of,  589,  601 
telangiectatic,  589 
thrombosis  in,  604 
treatment  of,  605,  608 
2;-rays  in,  225 
Fibroma  of  broad  ligaments,  699 
of  cervix,  582 
of  Fallopian  tubes,  701 


Fibroma  of  ovarian  ligament,  699 
of  ovary,  715 
of  round  ligaments,  700 
of  urethra,  851 
of  uterus,  575 
of  vagina,  569 
of  vulva,  559 
Fibromyoma  of  uterus,  575 

adenofibromyoma,  585 
chnical  characteristics  of,  591 
complicating  pregnancy,  630 
degenerations  of,  586 
diagnosis  of,  anatomical,  577 
chnical,  592 
differential,  597 
microscopic,  584 
effect  of  neighboring  organs,  604 
etiology  of,  575 
histogenesis  of,  576 
operations  for,  608 
treatment  of,  805 
Fibromyxoma  cystoma  of  fimbriae,  701 
Fistulse  of  anus,  804 
of  bladder,  807 
enterovaginal,  806 
rectolabial,  805 
rectoperineal,  804 
rectovaginal,  804 
of  rectxma,  804 
of  ureter,  876,  821 
of  m-ethra,  804 
of  vagina,  821 
vesicocervical,  810 
vesico-uterine,  810 
vesicovaginal,  807 
Follicular  abscess  of  ovarj',  489 
cysts  of  ovary,  703 
degeneration  of  ovary,  484 
erosions  of  cervix,  417 
Foreign  bodies  in  abdomen,  930 

causes  of  pelvic  inflammation, 

393 
in  urethra,  851 
in  uterus,  797 
FuU  tub  bath,  193 
Furunculous  vulvitis,  400 


Gall-bladder,  distended,  differentiated 

from  ovarian  cysts,  729 
Gangrene  of  fetus  in  ectopic  pregnancy, 
154 
of  fibroids,  589 

of  lungs  following  operations,  908 
of  vulva,  396 
Gas  anesthesia,  249 

General   lowered  vitahtj'-,  contra-indica- 
tion  to  operation,  243 
peritonitis,  493 
Genital  organs,  development  of,  263 

normal  secretions  of,  63 
Genito-urinary  fistula,  806 
urethral,  806 
vesical,  807 


942 


INDEX 


Gerdto-urinary  fistula,  vesicocervical,  810 
vesico-uterine,  810 
vesicovaginal,  807 

Gellhom,   acetone  treatment  of  inoper- 
able cancer,  677 

Gestation,    ectopic,     143.      See    Extra- 
uterine pregnancy. 

Glass  plug,  Sims',  413 

Gloves,  rubber,  252 

Gonorrhea  in  children,  536 
in  women,  520 

Bartholinitis,  401,  521,  524 
cause    of    pelvic    inflammation, 

392 
cystitis,  522,  524,  534 
diagnosis  of,  522 
etiology  of,  520 
gonococcus  in,  520 
location  of  infection  in,  528 
ovaritis,  522,  527,  534 
peritonitis,  501,  522 
prevention  of,  434 
prognosis  of,  527 
relation  of,  to  sterihty,  527 
risks  to  offspring  in,  528 
salpingitis,  522,  526,  534 
treatment  of,  529 
of  urethi-a,  520,  523.  530 
of  uterus,  521,  525,  532 
vaccines  in,  538 
vaginitis,  525,  529,  531 
vulvitis,  398,  521,  524,  531 

Graafian  follicles,  384 


H 


Half  tub  bath,  192 
Heart  lesions,  contra-indications  in  opera- 
tions, 242 
in  uterine  fibroids,  602 
Heat,  electrical,  applied  to  abdomen,  210 
Hematocele,  differentiated  from  ovarian 
cyst,  722 
in  ectopic  pregnancy,  167 
Hematocolpos  from  atresia  vaginae,  272 
Hematoma,  causing  uterine  hemorrhage, 
30 
diff  erenitiated  from  fibroids  of  uterus, 

600 
of  ectopic  pregnancy,  167 

from  pelvic  cellulitis,  515 
of  ovary,  480 
of  vulva,  395 
Hematometra  from  atresia  vaginae,  272 
Hematosalpinx,  450,  476 

from  atresia  vaginae,  272 
from  ectopic  pregnancy,  469 
from  salpingitis,  450 
due  to  twisting  of  tube,  462 
Hemorrhage  from  genital  tract,  22 
in  anemia,  27 
in  arteriosclerosis  of  uterus, 

30 
in  cancer  of,  uterus,  29,  640 
causing  surgical  shock,  899 


Hemorrhage    from    genital    tract,    from 
cei'vix,  23 
in  congestion  of  pelvis,  27 
controlled  by  tampons,  211 
in    cystic    degeneration    of 

ovaries,  30 
emotions  causing,  27 
in  endometritis,  28 
in  hematoma,  30 
infectious  diseases  causing, 

27       _ 
intraperitoneal    in    ectopic 

pregnancy,  157 
menstrual,  23 
in  menopause,  33 
in  mucous  polyps,  28 
myopathic,  30 
in  obstetrics,  30 
into  ovarian  cysts,  733 
parauterine  inflammations, 

28 
passive  congestion  causing, 

27 
plethora  causing,  27 
in  purpuric  conditions,  27 
in  sarcoma  of  uterus,  29 
in    specific    infectious   dis- 
eases, 27 
subinvolution,  28 
in  syphihs,  32 

in  syncytioma  malignum,  29 
treatment  of,.  33 
from  tube  in  menstruation, 

26 
in  uterine  fibroids,  29,  600 
from  vagina,  23 
vicarious,  40 
from  vulva,  22 
x-rays    in    uterine    hemor- 
rhage, 225 
Hepatic  colic  differentiated  from  extra- 
uterine pregnancy,  163 
Heredity  in  cancer,  633 
in  ovarian  cysts,  706 
in  tuberculosis  of  genital  organs,  539 
in  uterine  fibroids,  575 
Hernia  of  ovary,  388 
of  tube,  388 
of  uterus,  381 
of  vagina,  302,  304 
Holden's  perineorrhaphy,  769 
Hot-air  therapy,  209 

contra-indications  to,  209 
indications  for,  209 
physiological  action  of,  209 
technic  of,  209 
compresses,  207 
pack,  210 
-water  bag,  207 
Hydatid  mole,  177 
Hydatids  of  Morgagni,  703 
Hydatidiform    degeneration    of    chorion, 

177 
Hydronephrosis  differentiated  from  ovar- 
ian cysts,  729 
Hydrosalpinx,  449,  476 


INDEX 


943 


Hydrostatic  bag,  414 
Hydrotherapy,  188 

baths,  189 

hot  compresses,  207 
hot-water  Jaag,  207 

ice  bag,  207 

intra-uterine  douche,  200 

saUne  injections,  202 

vaginal  douche,  196 

water  drinking,  208 
Hygiene  of  the  school  girl,  229 
Hymen,  anatomy  of,  267 

cysts  of,  269 

imperforate,  269 

malformations  of,  267 
Hypertrophic  endometritis,  426 
Hypertrophy  of  cervix,  553 

of  chtoris,  264,  553 

of  endometrium,  426 

of  labia,  553 

of  ovary,  286,  558 

of  vulva,  553 
Hypodermoclysis,  204 

in  hemorrhage,  203 

massage  in,  204 

preparation  of  field  for,  204 

quantity,  204 

in  shock,  203,  888,  901 

technic  of,  204 

temperature  of  solution,  204 
Hypoplasia  of-  cervix,  279 

of  Fallopian  tubes,  286 

of  ovary,  287 

of  uterus,  279 

of  vagina,  272 

of  vulva,  264 
Hypospadias,  266 

Hysterectomy  in  arteriosclerosis  of  uterus 
30 

in  bilateral  pyosalpinx,  471 

in  cancer  of  uterus,  660 

in  chronic  metritis,  442 

in  fibroids  of  uterus,  609 

in  inversion  of  uterus,  344 

in  perforation  of  uterus,  797 

in  prolapse  of  uterus,  331 

in  puerperal  infection,  436 

in  sarcoma  of  uterus,  698 

in  tuberculosis  of  uterus,  543 
Hysteromyomectomy,    complications  in, 
627 

conservation  of  ovaries  in,  626 

Kelly's  modification  of.  624 

supravaginal,  621 

vaginal,  620 
Hysterocele,  381 


Ice  appUcations  to  abdomen,  893 
Ileus,  903 

Immunity  in  gonorrhea,  521 
Impaction  of  fibroids,  601 
Incarceration  of  fibroids,  601 
massage  in,  216 


Incarceration,  pressure  therapy  in,  222 
Indoor  exercise,  230 
Infantile  cervix,  279 

Fallopian  tubes,  286 
ovaries,  287 
uterus,  279 
vulva,  263,  264 
Infection  of  fetus,  ectopic,  154 
of  fibroids  of  uterus,  589 
of  genital  organs,  389 
tuberculous,  539 
gonorrheal,  in  women,  520 
local,  following  operations,  908 
of  ovarian  cysts,  715,  734 
of  pelvic  hematoma,  152 
Infectious  diseases  causing  uterine  hem- 
orrhage, 27 
granulomas  of  Fallopian  tubes,  462 
Inflammations  of  Bartholinean  gland,  401 
of  cellular  tissue  of  pelvis,  510 
of  cervix,  415 

of  Fallopian  tubes,  446,  496 
classification  of,  447 
granulomata,  446 
treatment  of,  467 

conservative,  470 
non-operative,  468 
radical,  471 
of  ovaries,  483 
acute,  483 
of  peritoneum,  493 
of  uterus,  420,  438.    See  Metritis, 
of  vagina,  406.    See  Vaginitis, 
of  vulva,  397.    See  Vulvitis. 
Infundibular  tubal  pregnancy,  150 
Inoperable  cancer  of  cervix,  634 
treatment  of,  677 
Inspection  of  abdomen,  91 
of  external  genitals,  91 
Instrumental      and     digital     infections, 
392       . 
causing  pelvic  inflamma- 
tion, 393 
Instrumental  examinations,  118 

exploratory  puncture  and  inci- 
sion, 132 
uterine  curet,  126 

indications  for,  126 
contra-indications   for, 

127 
dangers  of,  128 
technic  of,  129 
in  treatment,  130 
dilators,  121 
sound, 122 
vaginal  speculum,  118 
vulsellum  forceps,  120 
Internal  hernia  differentiated  from  ec- 
topic pregnancy,  163 
Interstitial  fibroids  of  uterus,  583 

tubal  pregnancy,  150 
Intestinal  colic  differentiated  from  ectopic 
pregnane}^,  163 
obstruction  in  uterine  fibroids,  601 
Intraligamentary  cysts,  718 
fibroids,  629 


944 


INDEX 


Intraperitoneal    hemorrhage    in    ectopic 

pregnancy,  157 
Intra-uterine  douche,  200 
limitations  of,  201 
physiological  action  of,  201 
technic  of,  201 
Intravenous  injections,  205 
apparatus,  206 
indications  for,  205 
local  anesthesia  in,  206 
quantity  of,  206 
technic  of,  206 
temperature  of  solution,  206 
Inversion  of  uterus,  334 
anatomy  of,  336 
causes  of,  334 
clinical  diagnosis  of,  337 
differentiated     from     partially 
divided    uterus    with    a 
depression  in  the  fundus, 
340 
from  pedunculated  fibroid 
or  polyp  lying  within  the 
vagina,  339 
from  prolapsus  uteri,  340 
from  submucous  fibroid  ly- 
ing within  the  cavity  of 
the  uterus,  339 
from     submucous     fibroid 
with    partial     inversion, 
339 
operations  for,  342 
prophylaxis  of,  340 
reduction  by  taxis,  340 
treatment  of,  340 


Kelly-Pawlik    method    of   cystoscopy, 

839 
Knee-chest  position,  105,  106 
in  cystoscopy,  842 
in     reposition     of     retroverted 
uterus,  363 
Kraurosis  vulvaj,  546 


Labia,  absence  of,  263 
actinomycosis  of,  400 
anatomy  of,  264 
angioma  of,  393 

anomalous'developments  of,  263 
atresia  of,  263 
atrophy  of,  546 
cancer  of,  562 
cysts  of,  560 

dermoid,  560 

sebaceous,  559 
double,  263 
edema  of,  396 
enchondroma  of,  559 
erysipelas  of,  398 
fibroma  of,  559 


Labia,  gangrene  of,  396 

gonorrhea  of,  398 

hematoma  of,  395 

hemorrhage  from,  22 

hypertrophy  of,  264,  553 

infantile,  263 

inflammation  of,  397 

injuries  of,  762-764 

itching  of  (pruritis),  403 

kraurosis  vulvae,  546 

lipoma  of,  559 

neuroma  of,  559 

noma  pudendi,  397 

sarcoma  of,  567 

syphilis  of,  399 

tuberculosis  of,  399 

tumors  of,  559    . 

varicose  veins  of,  393 

wounds  of,  762 
Labor  comphcated  by  ovarian  tumors, 
731,  747 
prolapsus  uteii,  333 
utei-ine  fibroids,  630 

false,  157 

spurious,  157 
Laceration  of  cervix,  791 

immediate  repair  of,  793 
late  repair  of,  794 

of  perine\im,  762 

immediate  repair  of,  765 
late  repair  of,  782 

of  uterus,  797 

of  vagina,  763 

of  vulva,  762 
Lactation  atrophy  of  uterus,  549 
Latent  fibroids  of  uterus,  584 
L;iteroposition  of  uterus,  312 
Leakage  of  ovarian  cyst,  733 
Leucocytosis,  80 

inflammatory,  81 

in  malignancy,  82 

in  ovarian  tumors,  82 

posthemorrhagic,  80 

of  pregnancy,  80 

postpartum,  80 
Leucorrhea,  63 

in  cancer  of  uterus,  641 

diagnosis  of,  65 

douches  for,  199 

in  endometritis,  422 

in  infancy,  63 

normal  secretions,  63 

in  old  women,  54 

in  period  of  sexual  maturity,  64 

in  prolapsus  uteri,  325 

tampons  for,  213 

treatment  of,  65 

in  virgins,  64 
Ligation   of   veins    in    puerperal    sepsis, 
436 
in  varicose  veins  of  pelvis,  518 
of  vulva,  394 
Lipoma  of  Fallopian  tubes,  701 

of  vulva,  559 
Lithopedion  in  ectopic  pregnancy,  154 
Lithotomy  position,  101,  105 


INDEX 


945 


Liver,    tumors    of,    differentiated    from 

ovarian  tumors,  729 
Local  treatment,   187.     See  Non-opera- 
tive treatments, 
preparatory  to  operation,  243 
Lymphangioma  of  ovary,  716 


M 


Mackenrodt's     operation     for     vesico- 
vaginal fistula,  817 
Maldevelopments  of  genital  organs,  262 
Malformations  causing  sterility,  70 
of  Fallopian  tubes,  286 
of  genital  organs,  262 
of  ovaries,  286 

absence  of  one  dr  both,  286 
congenital  largeness,  286 

smallness,  287 
supernumerary,  287 
of  uterus,  276 

_  uterus  accessorius,  286 
bicornis,  282 
deficiens,  276 
didelphys,  286 

fetalis,  279 
rudimentarius,  279 
septus,  282 
unicornis,  280 
of  vagina,  270 

absence  of,  270 
atresia  of,  272 
blind  pouches,  276 
double  vagina,  275 
stenosis,  272 
of  vulva,  262 

absence  of,  262 
adhesions  of  prepuce,  265 
atresia  of,  262 

congenital  anomahes  of,  clitoris, 
264 
fissures,  265 
double  vulva,  263 
hypertrophy  of,  264 
infantile,  263 
Malignancy,    contra-indicating   massage, 
217 
in  ovarian  tumors,  742 
Malignant  degeneration  of  chorionic  villi, 
177 
of  fibroids  of  uterus,  604. 
of  ovarian  cysts,  734 
Malposition,  causing  sterUity,  70 
of  Fallopian  tubes,  382 

changes  in  position,  384 
hernia,  388 
normal  position,  384 
of  ovaries,  384 

changes  in  position,  356 
descensus  ovarii,  386 
hernia  of  ovary,  388 
normal  position,  384 
prolapse,  386 
of  uterus,  305 

anteflexion  of,  347 

60 


j  Malposition   of  uterus,  anteposition  of 
309 
anteversion  of,  345 
hernia  of,  381 
inversion  of.,  334 
lateioposition  of,  312 
pathological  filiation  of,  308 

mobility  of,  308 
prolapse  of  pregnant  uterus,  333 
prolapsus  uteri,  315 
retroposition,  312 
retroversioflexion,  352 
of  the  vagina]  walls,  288 
cystocele,  288 
rectocele,  299 
vaginal  hernia,  302 
Mammary  glands  in  ectopic  pregnancy. 

156 
Marriage  of  near  relative,  cause  of  steril- 
ity, 69 
Martin's  amputation  of  cervix  (circular 

amputation),  796 
Massage,  abdominal,  220 

pelvic,  216 
Mechanical  disturbances,  causes  of  pelvic 

inflammation,  393 
Membranous  dysmenorrhea,  45 
Menorrhagia.    See  Uteiine  hemorrhage. 

x-rays  in  treatment  of,  225 
Menopause,  33,  73 

clinical  manifestations  of,  75 

corpus  luteum  in,  77 

delayed,  74 

influence  of   morbid   conditions  on, 

76 
management  of,  76 
premature,  73 
time  of  appearance  of,  74 
Menstrual  moHmina,  40 
Menstruation,  23 
anatomy  of,  24 
bathing  during,  195 
fibroids  of  uterus,  influence  on,  576 
frequency  of,  23 
pain  during,  44 
physiological  absence  of,  37 
precocious,  23 
quantity  of,  24 
time  of  onset,  23 
tubal,  26 

-  pregnancy,  156 
wathout  ovaries,  26 
Mensuration  of  abdomen,  99 

of  pelvis,  99 
Mental  shock  causing  amenorrhea,  38 
Mesentery,  chylous  cj^sts  of,  729 
Metastatic  foci  of  cancer  of  uterus,  657 

of  chorioepithelioma  malignum,  184 
Metritis,  434 
acute,  434 
chi-onic,  438 
treatment  of,  434 
coli,    differentiated   from   cancer   of 

cervix,  652 
gonorrheal,  525 
Microcystic  degeneration  of  ovaries,  4S4 


946 


INDEX 


Microscopic    examinations    of   scrapings 
and     excised 
parts,  133 
fixing     specimens, 

136 
frozen   specimens, 

134 
hardening  and  em- 
bedding, 136 
inspection     of 
uterus  after  re- 
moval, 139 
removal  of  uterine 

tissue,  133 
staining     and 

mounting,  138 
test  curettage,  134 
excision        of 
cervix,   134 
Miscarriages,  in  case  taking,  21 
Mittelschmertz,  46 

treatment  of,  48 
Mole  formations,  154 
Morning  sickness  in  tubal  pregnancy,  156 
Mortality  of  cancer  of  cervix,  660 
of  fibroids  of  uterus,  605 
of  ovariotomy,  752 
Movable     kidney,     differentiated     from 

extra-uterine  pregnancy,  164 
Mucous  patch  on  cervix  (erosions),  416 
polyps,  416 

causing  uterine  hemorrhage,  28 
differentiated  from  cancer,  655 
Multiple  ectopic  pregnancy,  154 
Muscular  insufficiency  of  uterus,  30 
Mustard  plaster,  211 
Myoma  of  Fallopian  tubes,  701 

of  ovary,  716 
Myxoma  of  ovary,  716 
Myxomatous  degeneration  of  fibroids,  589 


N 


Nakcosis,  examination  under  chloroform, 

ether,  112 
Nasal  dysmenorrhea,  46 
Nationality  in  case  taking,  21 
Nauheim  bath,  195 
Nervous    diseases    causing    amenorrhea, 

38 
Neuroma  of  vulva,  559 
New  formations  causing  sterility,  71 
of  Fallopian  tubes,  700 
carcinoma,  701 
cystic,  703 
dermoid  cysts,  701 
fibroid,  701 
fibromyxoma  cystoma, 

701 
lipoma,  701 
papilloma,  700 
polyps,  701 
sarcoma,  701 
of  ovary,  703 

carcinoma,  712 


New  formations  of  ovary,  connective-tis- 
sue tumors, 
715 
angioma,  715 
enchondroma, 

715 
fibroma,  715 
lymphangi- 
oma, 715 
myoma,  715 
myxoma,  715 
osteoma,  715 
cysts,  703 

dermoid,  714 
endothelioma,  717 
mahgnancy  of,  742 
simple,  703 
mortality  of,  752 
ovariotomy,  abdominal,  739 

vaginal,  737 
postoperative  complications  of, 

744 
of  pelvic  ligaments,  699 

broad  ligaments,  699 
ovarian  ligaments,  699 
round  ligaments,  700 
of  uterus,  carcinoma,  623 

chorioepithelioma     malig- 

num,  174 
endothelioma,  692 
fibromyoma,  575 
of  vagina,  567 

carcinoma,  570 
cysts,  567 
endothelioma,  574 
fibromyoma,  569 
sarcoma,  574 
syncytioma,  574 
of  vulva,  559 
cancer,  562 
cysts,  dermoid,  560 
of  hymen,  560 
vulvar,  560 
enchondroma,  559 
fibroma,  559 
lipoma,  559 
neuroma,  559 
sarcoma,  567 
Nitze  cystoscope,  830 
Noble  operation  for  cystocele,  297 

on  uterosacral  ligaments,  377 
Noma  pudendi,  397 

Normal    genital    tract,   bacteriology    of, 
84 
position  of  Fallopian  tubes,  382 
of  ovaries,  384 
of  uterus,  305 
secretions  of  genital  organs,  63 

of     body     of     uterus, 

63 
of  cervix,  63 
of  Fallopian  tubes,  63 
of  vulva,  63 
Nourishment  after  operation,  891 
Nutritive  changes  in  fibroids  of  uterus 
601 


INDEX 


947 


Obesity,  causing  sterility,  69 
Occupation  in  case  taking,  20 
Omental  tumors,  differentiated  from  ovar- 
ian tumors,  724 
One-child  sterility,  68 
Oophoritis,  483.     See  Ovaritis. 
Operating  room,  contents  of,  260 
room  in  hospital,  257 

in  private  home,  259 
table,  warming  the,  257 
Organ  of  Rosenmuller,  385 
Organotherapy,  227 
Osteoma  of  ovary,  716 
Osteomalacia,  x-rays  in,  225 
Ovarian  abscess,  761 

cysts,  complicating  pregnancy,  735 

exploratory     puncture 

of,  735 
fate  of,  736 

malignant  degenera- 
tion of,  735 
differentiated  from  ascites,  725 
from    bladder,     distended, 

723 
from     echinococcus     cysts, 

724  _ 

from     ectopic     pregnancy, 

160,  723 
from  fatty  tumors,  729 
-    from  fibroids,  721 
from  hematocele,  722 
from  hematoma,  722 
from  hydronephrosis,  729 
from  hydrosalpinx,  461 
from  obesity,  729 
from  pancreatic  cyst,  728 
from  parametritic  abscess, 

721 
from  parovarian  cyst,  724 
from  pericecal  abscess,  722 
from  perimetritic  exudate, 

721 
from  retroflexed  pregnancy 

of  uterus,  722 
from  splenic  tumor,  728 
from  tumor  of  hver,  729 
tumors    of    omentum, 
724 
from  uterine  pregnancy,  723 
extract,  227 

ligament,  cancer  of,  699 
fibroma  of,  699 
sarcoma  of,  699 
pregnancy,  151 
tumors,  703 

adherent,  730 
bilateral,  729 

complicating  pregnancy,  744 
hemorrhage  into,  733 
leakage  of,  733 
malignancy  of,  742 
rupture  of,  732 
suppuration  of,  734 
torsion  of  pedicle  of,  731 


Ovaritis,  483 

acute  gonorrheal,  483 

septic,  483 
chronic,  483 

diagnosis  of,  clinical,  490 
acute  stage,  490 
chronic  stage,  490 

differential,  491 
treatment  of,  492 
Ovariotomy,  abdominal,  739 
comphcations  of,  750 
contra-indications  of,  737 
for  dysmenorrhea,  750 
effect  of,  on  menstruation,  39 
indications  for,  736 
in  intrahgamentary  cysts,  741 
mortahty  of,  752 
vaginal,  736 
Ovary,  abscess  of,  489 
absence  of,  286 
accessory,  287 
anatomy  of,  384 
anomahes  of,  286 
atrophy  of,  550 
bacteriology  of,  88 
cancer  of,  712 
changes  in  position  of,  386 
circulatory  disturbances  in,  480 
congestion  of,  491 
conservative  operations  on,  753 
cystic  degeneration  of,  30 
cysts  of,  703 

corpus  luteum,  703 
displacements  of,  384,  386 
endothelioma  of,  717 
fibroma  of,  715 
follicular  hemorrhages  in,  487 
hematoma  of,  480 
hemorrhages  into,  482 
hernia  of,  388 
histology  of,  385 
hypertrophy  of,  558 
infiammations  of,  483 

treatment  of,  492 
maKormations  of,  286 
menstruation  without  ovaries,  26 
myoma  of,  715 
new  formations  of,  703 
sarcoma  of,  715 
supernumerary,  287 
torsion  of  pedicle  of,  531 
tuberculosis  of,  541 
txunors  of,  703 


Pain  in  cancer  of  uterus,  641 
during  menstruation,  41 
rehef  from,  after  operation,  890 
in  retroversioflexion,  358 

Palpation  of  abdomen,  93 

Pancreatic     cysts,     differentiated    from 
ovarian  cysts,  728 

Papillary  erosions  of  cervix,  417 

Papilloma  of  Fallopian  tubes,  700 


948 


INDEX 


Papilloma  of  ovaxy,  709,  741 
Parafiin  sections,  137 
Parametric  exudations,   differentiated 
from  ovaritis,  492,  461 
from  pyosalpinx,  461 
Parametritis,  510 
acute,  510 
atrophicans,  309 
chronic,  512 
posterior,  309 
Parametrium,  cancerous  invasion  of,  655 
Parasites  of  Fallopian  tubes,  466 
ParatjT)hlitic      exudates,     differentiated 

from  pelvic  cellulitis,  515 
Para-uterine  inflammations,  510 

causing  uterine  hemoiThage,  28 
Paravaginitis,  411 
Parovarian  cj^sts,  718 

differentiated  from  hj^drosalpinx, 
461 
from  ovarian  cyst,  724,  730 
Parovarium,  385 

Passive  congestion  causing  uterine  hemor- 
rhage, 27 
Pathological,  fixation  of  uterus,  308 

mobiUty  of  uterus,  308 
Pedunculated  fibroid  of  uterus,  581 
Pelvic  abscess,  516 

cellular  tissue,  bacteriology  of,  89 
cellulitis,  510 
acute,  510 
chronic,  512 
classification  of,  510 
definition  of,  510 
diagnosis  of,  512 
differentiated  from  hematoma, 
515 
from  malignancy,  516 
from  paratjT^hhtis,  515 
from  psoas  abscess,  516 
from  subserous  fibroids,  515 
exudate,   differentiated  from   extra- 
uterine pregnancy,  159 
floor,  wounds  of,  762 
hematocele,  161 

hematoma,    differentiated   from   ec- 
topic pregnancy,  161 
from  pelvic  cellulitis,  510 
infections,  389 

barriers  to,  390 
causes  of,  390 
local  causes  of,  392 
inflammation,  389 

causing  sterUity,  71 
massage  in,  216 
treated  by  douches,  200 
by  tampons,  212 
massage,  215 

contra-indications,  216 
indications  for,  216 
physiological  action  of,  216 
technic  of,  217 
Pelvimeter,  117 
Percussion  of  abdomen,  97 
Pericecal     abscess,     differentiated    from 
ovarian  cyst,  722 


Perimetric  exudate,   differentiated  from 

ovarian  cyst,  721 
Perimetritis,  pressure  therapy  in,  221 
Perineorrhaphy,  763 

after-treatment  of,  780 

Emmet's,    for    complete    laceration, 
782 
for  incomplete  laceration,  774 

Holden's,  769 

Tait's,  for  complete  laceration,  783 
for  incomplete  laceration,  776 
Perineum,  immediate  repau-  of,  763,  766 

late  repair  of,  764,  768 
Periovaritis,  756 
Peritoneal  adhesions,  506 

exudates,  506 
Peritoneum,  bacteriologj^  of,  89 
Peritonitis,  493 

adhesions  in,  506 

definition  of,  503 

diagnosis  of,  cUnical,  507 
differential,  507 

from    pelvic    celluHtis, 
515 

etiology  of,  505 

exudates  in,  506 

following  operations,  909 

general,  493 

gonorrheal,  501 

non-septic,  493 

pathology  of,  505 

pelvic,  503 

postoperative,  495 

puerperal,  500 

traumatic,  493 

treatment  of,  508 

tuberculous,  502,  544 
PerityphUtis,  differentiated  from  ovaritis, 

492 
Pessaries  in  anteflexion,  348 

in  cystocele,  293 

in  prolapsus  uteri,  330 

in  retroversioflexion,  364 

stem,  in  dysmenorrhea,  54 
Phantom  tumor,  724 
Phlebitis,  contra-indicating  massage,  217 

in  fibroids  of  uterus,  604 
Physical  training  in  schools,  230 
Pituitrin,  228 

Plethora,  causing  uterine  hemorrhage,  27 
Pneumonia,  postoperative,  906 
Polypoid  endometritis,  426 
Polyps,  causing  uterine  hemorrhage,  28, 
129 
•  of  cervix,  415 

mucous,  426 
Position  of  patient,  after  operation,  889 
Postabortive  endometritis,  424 
Postoperative  compUcations,  886 
Precocious  menstruation,  23 
Pregnancy  in  bicornate  uterus,  160 

comphcating  cancer  of  cervix,  676 
fibroids,  600 
ovarian  cysts,  735 

contra-indicating  massage,  217 
passage  of  soimd,  127 


INDEX 


949 


Pregnancy    differentiated    from  ovarian 
cyst,  723 
influence  of  gonorrhea  on,  528 
of  uterine  fibroids  on,  576 
labor,  and  puerperium  complicated 
by  ovarian  cysts,  744 
prolapsus  uteri,  339 
uterine  fibroids,  630 
in  a  retroverted  uterus  differentiated 

from  ectopic  pregnancy,  158 
in  a  rudimentary  horn,  160 
Pregnant  uterus,  prolapse  of,  333-339 
Premature  menopause,  73 
Preparation  of  field  of  operation,  244 
for  operation  in  the  home,  258 
of  patient  for  operation,  242 

choice  of  local  or  general  anes- 
thesia, 246 
combined   gynecological   opera- 
tions, 250 
diet,  251 
examinations  for  contra-indica- 

tions,  242 
local  treatment,  243 
of  surgical  utensils,  254 
bandages,  255 
basins,  255 
brushes,  254 
catgut,  255 
cotton,  255 
gauze,  255 
linen,  255 

rubber  drainage  pads,  255 
silk,  255 
sponges,  255 
towels,  255 
Prepuce,  adhesions  of,  265 
Present  complaints  in  case  taking,  22 
Pressure  therapy,  220 

indications  for,  221 
technic  of,  222 
Progressive  tissue  changes,  551 
Prolapse  of  anterior  vaginal  wall,  288 
of  posterior  vaginal  wall,  288 
of  pregnant  uterus,  333 
of  urethra,  848 
Prolapsus  uteri,  differentiated  from  inver- 
sion, 34 
prophylaxis  of,  327 
vaginae,  318 
Pruritus  vulvse,  403 

x-rays  in,  224 
Pseudodiphtheritic  endometritis,  426 
Psoas  abscess,  differentiated  from  pelvic 

exudate,  516 
PubUc  play  grounds  and  baths,  230 
Puerperal  endometritis,  424 

infection,  cause  of  pelvic  inflamma- 
tion, 392 
curettage  for,  436 
hysterectomy  for,  436 
hgation  of  veins  in,  436 
peritonitis  due  to,  500 
removal  of  placental  tissue  in, 

436 
of  vulva,  399 


Puerperal  peritonitis,  500 

vaginitis,  406 

vulvitis,  399 
Pulmonary  embolism,  902 
Pxmcture  of  uterus,  799 
Purpuric     conditions,     causing     uterine 

hemorrhage,  27 
Pus  tubes,  455 

Pyemia  following  operation,  911 
Pyosalpinx,  455 

acute,  456 

chronic,  457 

treatment  of,  470 

vaginal  drainage  in,  476 


R 


Radical  abdominal  operation  for  cancer 

of  cervix,  655 
Rectocele,  299 

anatomy  of,  299 
diagnosis  of,  301 
etiology  of,  299 
symptoms  of,  300 
treatment  of,  302 
Rectolabial  fistula,  804 
Rectoperineal  fistula,  804 
Rectovaginal  fistula,  804 
hernia,  299 
examination  of,  112 
gonorrhea  of,  527 
Recurrence  of  uterine  cancer,  678 

fibroids,  584 
Recurrent  ectopic  pregnancy,  144 
Refiex    symptoms    in    retroversioflexion, 

358 
Renal  colic,  differentiated  from  ectopic 

pregnancy,  163 
Replacement    of    uterus     in     inversion, 
340 
in  prolapsus,  329 
Retained  placental  tissue  differentiated 
from  cancer,  654 
use  of  curet  in,  126 
Retrogressive  changes  in  fetus  of  ectopic 
pregnancy,  154 
tissue  changes,  546 
Retroposition  of  uterus,  310 
Retroversioflexion  of  uterus,  352 

differentiated  from  anteflexion, 
362 
from  fibroids,  362 
from  retroposition,  361 
treatment      of      acute      stage, 
362 
of  chronic  stage,  362 
Rodent  ulcer  of  vulva,  395,  396 
Rontgen  rays,  223 
Round  ligaments,  cancer  of,  700 
fibroma  of,  700 
sarcoma  of,  700 
Rudimentary  Fallopian  tubes,  286 
ovaries,  287 
uterus,  279 


950 


INDEX 


S 


Social  state,  in  case  taking"  21 
Sacro-iliac  joint,  mobility  of,  57 
Sactosalpinx,  contents  of,  459 
diagnosis  of,  458 

differential,  459 
hemorrhagica,  458 
purulenta,  455-458 
serosa,  458 
treatment  of,  476 
twisted  pedicle  of,  462 
Saline  injections,  202 

general  indications  for,  203 
enteroclysis,  203 
hypodermoclysis,  204 
intravenous  injections,  205 
Salpingectomy,  478 
Salpingitis,  catarrhal,  447 

classification  of,  447 
differentiated  from  appendicitis, 
459 
from    new    formations    of 

tubes,  461 
from  ovarian  cysts,  461 

timaors,  461 
from  parametric  exudates, 

461 
from  parovarian  cysts,  461 
from  subserous  fibroids,  460 
gonorrheal,  526 
isthmica  nodosa,  449 
purulent,  453 
acute,  454 
chronic,  455 

clinical  diagnosis  of,  456 
etiology  of,  453 
tuberculous,  462 
Salpingostomy,  478 
Sarcoma  of  broad  hgaments,  699 
of  cervix,  653 
choriocellulare,  174 
of  Fallopian  tubes,  701 
of  ovary,  716 
of  urethra,  851 
uterine  hemorrhage  in,  29 
of  uterus,  693 

anatomy  of,  694 
diagnosis  of,  chnical,  697 

microscopic,  696 
etiology  of,  693 
prognosis  of,  697 
treatment  of,  698 
of  vagina,  574 
of  vulva,  567 

x-rays  in  treatment  of,  224 
Sarcomatous     degeneration     of     uterine 

fibroids,  591,  697 
School  girl,  hygiene  of,  229 
Schools,  physical  training  in,  230 
Schroeder's  amputation  of  cervix,  795 
Schuchardt  operation  for  cancer  of  cervix, 

662 
Sea  bath,  194 

Sebaceous  cysts  of  vulva,  559 
Senile  endometritis,  425 


Senile  vaginitis,  409 

Septic  intoxication  following  operation 
910 

peritonitis,  494 

anatomy  of,  495 
causes  of,  essential,  494 

predisposing,  494 
clinical  manifestations  of,  495 
prognosis  of,  496 
treatment  of,  496 
Septicemia  following  operation,  910 
Serum  and  organotherapy,  227 

antitoxin  of  diphtheria,  227 
corpus  luteum,  228 
ovarian  extract,  227 
pituitrin,  228 
thyroid  extract,  228 
tuberculin,  545 
Sexual  excess,  causing  sterihty,  69 

incompatibility,  causing  sterihty,  69 
Shock,  surgical,  897 
Shower  bath,  191 
Simon's  speculum,  118 
Simple  cysLs  of  ovary,  703 
erosion  of  cervix,  417 
vaginal  hysterectomy  for  cancer  of 
cervix,  660 
Simpson's  operation  on  round  ligaments, 

376 
Sims'  glass  vaginal  plug,  272 

operation  for  vesicovaginal  fistula, 

815 
retractor,  118 
Sitz  bath,  194 
Sound,  uterine,  122 
Speculum,  vaginal,  118 
Sphincter  ani  muscle,  repair  of,  786 
Spiegelberg's  sign  of  cancer,  656 
Spinal  anesthesia,  250 
Splenic  tumors,  differentiated  from  ovar- 
ian tumors,  728 
Spurious  labor,  157 
Squamous-cell  cancer,  634 

of  body  of  uterus,  649 
of  cervix,  634 
Static  backache,' 57 
Stenosis  of  vagina,  272,  790 
Sterihty,  67 

alcohohsm  in,  69 

anemia  in,  69 

conditions    essential   to  conception, 

67 
definitions' of ,  67 
etiology  of,  68 

gonorrhea,  in  relation  to,  527 
one-child,  67 
in  retroversioflexion,  357 
treatment  of,  72 
Stimulation  after  operation,  888 
Stricture  of  ureter,  883 

of  m-ethra,  847 
Subinvolution  of  uterus,  555 

causing  pelvic  inflammation,  395 
uterine  hemorrhage,  28 
Submucous  fibroids,  582 
Subserous  fibroids,  583 


INDEX 


951 


Supernumerary  ovaries,  287 

causing  menstruation,  26 
Supporter,  abdominal,  896 
Suppuration  of  fibroids  of  uterus,  589 

of  hematoma,  152 

of  ovarian  cyst,  734 
Suppurative  salpingitis,  453 
Svu-gical  instruments,  sterilization  of,  356 

shock,  897 
Swabs,  225    _ 

in  chronic  metritis,  439 
Syncytioma  maUgnmn,  174 

causing  uterine  hemorrhage,  29 

of  uterus,  74 

of  vagina,  574 
Syphilis  of  Fallopian  tubes,  466 

of  uterus,  32 

of  vagina,  573 

of  vulva,  399 
Syphilitic  uterine  hemorrhage,  32 


Tampons,  211 
drainage,  214 
hemorrhage,  211 
indications  for,  211 
pelvic  inflammation,  212 
protection  against  infection,  215 
uterine  support,  215 
Taxis  in  inversion  of  uterus,  340 
Telangiectatic  fibroids  of  uterus,  589 
Therapeutic  application  of  baths,  96 
Thrombosis,    contra-indicating  massage, 
217 
in  fibroids  of  uterus,  604 
Thyroid  extract,  228 
Todd-Gilham  operation,  368 
Torsion  of  fibroid  of  uterus,  593,  601 
of  pedicle  of  ovarian  cyst,  731 
of  uterus,  315 
Trachelorrhaphy,  794 
Traumatic  peritonitis,  493 
Traumatisms  causing  sterility,  71 
Treatment,  non-operative,  187 
counterirritation,  211 
electricity,  228 
hot  air,  209 

pack,  215 
hydrotherapy,  188 
pelvic  massage,  215 
pressure  therapy,  220 
serima  and  organotherapy,  227 
swabs,  225 
tampons,  211 
vaginal  douche,  196 
x-ray  therapy,  223 
Trigone,  827 
Tubal  abortion,  152 
menstruation,  26 

pregnancy,  143.     See  Extra-uterine 
pregnancy. 
Tuberculin,  545 

Tuberculosis  of  Fallopian  tubes,  541 
of  ovaries,  541 


Tuberculosis  of  pelvic  organs,  539 

contra-indicating   massage, 

217 
etiology  of,  539 
Tuberculous  cystitis,  860,  863 

endometritis,  differentiated  from 

cancer,  655 
peritonitis,  502,  544 

treatment  of  medical,  502 
sm-gical,  503 
salpingitis,  462,  541 

avenues  of  extension,  463 
diagnosis  of,  anatomical,  464 

clinical,  465 
etiology  of,  462 
treatment  of,  478 
ulcer  of  cervix,  differentiated  from 
cancer,  651 
of  uterus,  541 
of  vagina,  540,  573 
vaginitis,  408,  540 
vulvitis,  399,  540 
Tuboovarian  abscess,  489 

cyst,  450,  703 
Tuboperitoneal  gestation,  148 
Tumors  of  bladder,  865 

of  Fallopian  tubes,  carcinoma,  701 
cystic,  701 
dermoid  cysts,  701 
differentiated  from  salpin- 
gitis, 461 
fibroma,  701 

fibromyxoma  cystoma,  701 
lipoma,  701 
myoma,  701 
papilloma,  700 
polyps,  701 
sarcoma,  701 
of  ovary,  703 

carcinoma,  714 
connective  tissue  tumors,  715 
angioma,  715 
enchondroma,  715 
endothelioma,  717 
fibroma,  715 
lymphangioma,  715 
malignancy  in,  742 
mortality  of,  752 
myoma,  715 
myxoma,  715 
osteoma,  715 
ovariotomy,  736 
abdominal,  739 
complicating 
pregnancy, 
744 
conservative 
operations, 
753 
postoperative 
complications 
of,  744 
vaginal,  737 
sarcoma,  715 
cysts,  simple,' 703 

corpus  luteum,  703 


952 


INDEX 


Tumors  of  ovary,  cysts,  simple,  follicular, 
703 
tuboovarian,  703 
of  pelvic  ligaments,  699 

of  broad  ligaments,  699 
of  ovarian  ligaments,  699 
of  round  ligaments,  700 
treatment  of,  700 
of  uterus,  carcinoma,  632 
endothelioma,  692 
fibromyoma,  575 
sarcoma,  693 

syncytioma  malignum,  174 
of  vagina,  cancer,  570 
cysts,  567 
endothelioma,  574 
fibromyoma,  569 
sarcoma,  574 
syncytioma,  574 
of  vulva,  cancer,  562 
cysts,  560 

dermoid,  560 
sebaceous,  559 
fibroma,  559 
lipoma,  559 
neuroma,  559 
sarcoma,  567 
Turkish  bath,  195 

Twisted   pedicle   of   fibroids   of    uterus, 
593 
of  ovarian  cyst,  731 


U 


Ulcerative  vaginitis,  407 
Ulcers  of  cervix,  420 

cancerous,  634 

decubitus,  420 

tuberculous,  420 
in    prolapsus    uteri,    treatment    of, 

329 
of  vagina,  decubitus,  408,  410,  573 

differentiated  from  cancer,  573 

diphtheritic,  408,  410 

puerperal,  408,  410 

syphilitic,  408,  410,  573 

tuberculous,  408,  410,  573 
of  vulva,  399 

rodent,  395,  396 

syphiUtic,  399 

tuberculous,  399 
Ureter,  869 

anatomy  of,  869 

calculus  of,  881 

congenital  anomalies,  874 

catheterization  of,  870 

examination  of,  870 

fistula  of,  806,  821 

hydroureter  and  hydronephrosis,  884 

inflammation  of,  876 

obstruction    of,    calculus,    stricture, 

878 
palpation  through  vagina,  112 
physiology  of,  869 
stricture  of,  883,  884 


Ureteral  orifices,  827 
Ureteritis,  876 
Urethra,  824 

absence  of,  845 
anatomy  of,  825 
atresia  of,  845 
carcinoma  of,  851 
calculus  of,  881 
dilatation  of,  846 
dislocation  of,  848 
displacement  of,  846 
epispadias,  846 

examination  of,  methods  of,  829 
catheter  and  sound,  830 
cystoscopy,  830 
inspection,  830 
Kelly-Pawlik,  830 
Nitze,  830 
palpation,  829 
percussion,  829 
urethroscopy,  830 
fibroma  of,  851 
fistula  of,  804 
foreign  bodies  in,  851 
hypospadias,  846 

inflamniation  of,  521,  523,  530,  848 
inspection  of,  83 
malformations  of,  845,  846 
acquired,  846 
congenital,  845 
newgrowths  of,  850 
obstruction  of,  878 
palpation  of,  829 
physiology  of,  825 
prolapse  of,  848 
sarcoma  of,  851 
stricture  of,  847,  883 
tumors  of,  850 
Urethral  caruncle,  851 
fistulse,  806 

speculum,  introduction  of,  830 

Urethritis,  848,  871 

acute,  848 

chronic,  849 

Urethroscopy,  830 

Uterine  curet,  126 

contra-indications  for,  127 
dangers  of,  128 
indications  for,  126 
technic  of,  129 
in  treatment,  130 
decidua  in  ectopic  pregnancy,  157 
dilators,  121 
fibroids,     575.       See     Fibromyoma 

uteri, 
hemorrhage,  27 

causes  of  local,  28 

systemic,  27 
character  of  blood,  33 
treatment  of,  33 
x-rays  in,  225 
pregnancy,  complicated  by  a  tubal 
or  ovarian  swelhng,  159 
differentiated       from      uterine 
fibroids,  577 
sound,  122 


INDEX 


953 


Uterine  sound,  contra-indications  to  use 
of,  125 

dangers  in  use  of,  125 

indications  for,  123 

preliminary  procedures,  123 
support    by    pessaries.       See    Pes- 
saries. 

by  tampons,  215 
Uterus,  abscess  of,  345 
absence  of,  276 
accessory,  286 
anatomy  of,  307,  384 
anteflexion  of,  347 
anteposition  of,  309 
anteversion  of,  345 
arteriosclerosis  of,  30 
atrophy  of,  547 
bacteriology  of,  86 
bicomis,  282 
bUocularis,  282 
cancer  of,  632 

circulatory  distui'bances  in,  615 
deficiens,  276 
descent  of,  315 
development  of,  306 
didelphys,  286 
displacements  of,  288 
double,  286 
duplex,  286 
elevation  of,  313 
endothelioma  of,  692 
fibroid  tumors  of,  575 
fixation  of,  308 
foetalis,  279 
gonorrhea  of,  520 
hemorrhage  from,  27 
hernia  of,  381 
inflammation  of,  415 
injuries  of,  797 
inspection      of,      after      removal, 

139 
inversion  of,  334 
lactation  atrophy  of,  549 
lateral  position  of,  312 
malpositions  of,  305 
membranes  expeUed  from,  142 
membranous,  279 
normal  position  of,  305 
perforation  of,  797 
prolapse  of,  315 

removal  of,  30,  266,  331,  344,  381, 
436,  442,  471,  609,  620,  621,  626, 
660 
retroposition  of,  310 
retroversioflexion  of,  352 
rudimentarius,  279 
sarcoma  of,  693 
separatus,  286 
septus,  282 
subinvolution  of,  555 
superinvolution  of,  549 
test  curettage  of,  126 
torsion  of,  315 
tuberculosis  of,  541 
tumors  of,  575,  632 
unicornis,  280 


Vagina,  absence  of,  275 
atresia  of,  272,  790 
atrophy  of,  549 
bacteriology  of,  85,  389 
blind  pouches  of,  276 
cancer  of,  570 

chorioepithelioma  malignum  of,  574 
cystocele,  288 
cysts  of,  567 

differentiated     from     prolapsus 
uteri,  326 
decubitus  ulcers  of,  573 
displacements  of,  288 
double,  275 
endothelioma,  574 
examination  of,  digital,  100 
fibromyoma,  569 
gonorrhea  of,  525,  531 
hematocolpos,  272 
hemorrhage  from,  762 
hernia  of,  302 
inflammations  of,  406 
injuries  of,  763 
malformations  of,  270 
prolapse  of,  288,  299 
rectocele,  299 
sarcoma  of,  574 
stenosis  of,  790 
syncytioma  mahgnum  of,  574 
tuberculosis  of,  408,  540 
tumors  of,  567 
ulcers  of,  408,  410,  573 
Vaginal  celiotomy,  614 
douche,  196 

duration  of,  199 

medicated,  200 

physiological  action  of,  197 

posture  in,  197 

temperature  of,  199 

time  of  application  of,  199 
hernia,  302 

after-treatment  of,  305 

anatomy  of,  302 

diagnosis  of,  303 

etiology  of,  302 

symptoms  of,  302 

treatment  of,  304 
hysterectomy  for  cancer  of  body  of 
uterus,  679 
of  cervix,  660 

for  inversion  of  uterus,  344 

technic  of,  681 

for  uterine  fibroids,  609 
myomectomy,  609 
portion  of  cervix,  cancer  of,  570 

sarcoma  of,  694 
shortening  of  uterosacral  ligaments, 

377 
speculum,  118 
tampons  in  cystocele,  293 
walls,  malpositions  of,  288 
Vaginismus,  412 
Vaginitis,  406 

catarrhal,  407 


954 


INDEX 


Vaginitis,  condylomatous,  409 

emphysematous,  408 

gonorrheal,  525 

senile,  409 

tuberculous,  408 

ulcerative,  408 
Varicocele  of  broad  ligaments,  517 
Varicose  veins  of  vulva,  393 
Venereal  diseases  causing  sterility,  72 
Ventrofixation  of  uterus,  368 
Ventrosuspension,  365 
Vesical  fistula,  807 
Vesicocervical  fistula,  810 
Vicarious  menstruation,  40 
Vulva,  absence  of,  263 

anatomy  of,  290,  291 

anomalies  of,  262 

atresia  of,  263 

atrophy  of,  546 

bacteriology  of,  85 

cancer  of,  562 

circulatory  disturbances  in,  393 

condylomata  acuminati  of,  552 

cysts  of,  560 

dermoid,  560 
sebaceous,  559 

double,  263 

edema  of,  396 

elephantiasis  of,  550    , 

enchondroma  of,  559 

erysipelas  of,  398 

furunculosis  of,  401 

gangrene  of,  396 

gonorrhea  of,  398 

hematoma  of,  395 

hemorrhage  from,  22 

hypertrophy  of,  553 

infantile,  263 

inflammations  of,  397 

hpoma  of,  559 

malformations  of,  262 

neuroma  of,  559 

new  formations  of,  559 

operation  on,  preparation  for,  246 

sarcoma  of,  567 

syphilis  of,  399 

tuberculosis  of,  399,  540 

tumors  of,  559 

ulcers  of,  399 

rodent,  395,  396 
Vulsellum  forceps,  120 


Vulvitis,  397 

actinomycosis,  400 

barthohnitis,  401 

catarrhal,  simple,  397 

erysipelatous,  398 

furunculous,  401 

gonorrheal,  398,  531 

pruritus  vulvar,  403 

puerperal,  399 

syphilitic,  399 

treatment  of,  404 

tuberculous,  399 
Vulvovaginitis,  gonorrheal,  531 


W 


Waist  constriction  causing   circulatory 

disturbances  in  pelvis,  393 
Water  drinking,  208 

sterilized,  257 
Webster-Baldy  operation,  371 
Wertheim  operation  for  cancer  of  cervix, 

565 
Willis  operation  on  round  ligaments,  373 
Women,  gonorrhea  in,  520 
Wounds  of  cervix,  791 

of  pelvic  floor,  762 

of  uterus,  797 

of  vagina,  788 

of  vulva,  762 


X-RAY  therapy,  223 

in  cancer  of  cervix,  223 
in  eczema,  224 
in  lichen  planus,  225 
in  menorrhagia,  225 
in  osteomalacia,  225 
in  pruritus  vulvse,  224 
in  sarcoma  of  cervix,  224 
in  tuberculosis,  224 
in  uterine  fibroids,  225 


Zenker's  fluid,  136 

Zinc  chloride  in  chronic  metritis,  441 


DUE  DATE 


Printed 
in  USA 


'i 


yi 


v>^ 


Findley 

A  treatise  on  the  diseases 
of  women. 


KLlUl 

1913 

C.2 


COLUMBIA  UNIVERSITY 


0027094944 


W4      .    , 


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